Albumin-based colloid composition having at least one protected thiol region, methods of making, and methods of use

ABSTRACT

A composition comprising an albumin-based colloid composition having at least one protected thiol region, method of making the same, and method for use, including treating hypovolemic conditions such as capillary leak syndrome and shock, are disclosed. The composition also is modified with an indicator reagent such as chromophores.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of U.S. patent applications: Ser.No. 10/985,798 filed Nov. 9, 2004, which is a CIP of Ser. No.10/106,793, filed Mar. 26, 2002 now U.S. Pat. No. 7,037,895.

GOVERNMENT NOTICE

This invention was made with government support under CooperativeAgreement No. DAMD 17-97-2-7016 awarded by the U.S. Army MedicalResearch Acquisition Activity. The government has certain rights in theinvention.

DESCRIPTION

Throughout this application various publications are referenced bynumerals within parenthesis. Full citations for these publications maybe found at the end of this application, preceding the claims. Thedisclosure of these publications in their entireties are herebyincorporated by reference into this application in order to more fullydescribe the state of the art to which this invention pertains.

TECHNICAL FIELD

The present invention relates to the use of an albumin-based colloidcomposition, such as PEG-Alb, a polyethylene oxide (such as polyethyleneglycol (PEG) modified albumin, for treatment of such diverse hypovolemicconditions as shock, sepsis, bleeding and surgery. In a preferredembodiment the composition has at least one protected thiol region. Inanother embodiment, the albumin is modified with an indicator reagent.

BACKGROUND OF THE INVENTION

Massive resources have been expended on the development of potentialtherapies aimed at reversing the hypovolemia that is common to differentmanifestations of systemic inflammatory response syndrome (SIRS). Sepsisalone accounts for 750,000 cases per year in the United States,resulting in 200,000 deaths (1). This high mortality results from multiorgan dysfunction (MODS), which is associated with organ edema secondaryto capillary leak (CL). Patients with significant CL are typicallymanaged by administering resuscitation fluids containing osmolytes(e.g., albumin, starches, or dextrans) in addition to vasopressors andother supportive measures.

Capillary leak, which is present in different conditions such asmultiorgan dysfunction (MODS), sepsis, trauma, burn, hemorrhagic shock,post-cardiopulmonary bypass, pancreatitis and systemic capillarysyndrome, causes morbidity and mortality among a large number ofhospital patients. Capillary leak (CL) is a central component of MODS,secondary to severe sepsis and systemic inflammatory response syndrome(SIRS). It is characterized by increased capillary permeabilityresulting in interstitial edema and decreased tissue perfusion leadingultimately to organ failure and death. The leak aspect of capillary leaksyndrome (CLS) is reflected in both the release of water into theinterstitial space and high molecular weight components of serum whichordinarily would be retained within the capillaries.

Hypovolemic states often lead to hypoperfusion of vital organs, causingorgan dysfunction and ultimately resulting in morbidity and death (2).Hypovolemia can occur either rapidly, as with hemorrhagic shock, orprogressively due to an underlying disease, with both types involving asystemic inflammatory process. In hemorrhagic shock, hypovolemia occursdue to a rapid and sudden loss of intravascular volume. Uponresuscitation, an inflammatory process may be triggered in reperfusedtissues (ischemic—reperfusion injury) causing endothelial cell (EC)injury and capillary leak (CL) leading to a secondary hypovolemic state.In sepsis and other diseases, systemic inflammation is triggered by thedisease and in a similar sequence leads to EC injury, CL, and ultimatelyhypovolemic shock.

Resuscitation with plasma volume expanders remains a mainstay intreating hypovolemia, but with mixed results. The efficacy and safety ofvolume expanders, including both colloids (e.g., albumin and starches)and crystalloids, continue to be topics of intense research andcontroversy (3,4). The unpredictable effectiveness of albumin as aplasma expander may be linked to the severity of the underlying ECinjury (5). Specifically, if the endothelial integrity is compromisedsuch that albumin can readily extravasate, the leaking albumin mayexacerbate the oncotic gradient favoring CL, as opposed to reversing it.

Though the biological mechanisms that induce CL syndrome are poorlyunderstood, some evidence indicates the involvement of inflammatorycytokines. Fluid replacement with solutions of human albumin is onlymarginally effective since it does not stop the loss of albumin into theextravascular space. Albumin is important because it is responsible forplasma oncotic pressure as well as for retaining sodium ions in theblood.

Under normal conditions, albumin contributes to about 80% of the totalblood colloid osmotic pressure (6) and is ideally sized such that itextravasates at a low physiologic rate (7). In CL patients, 5% to 20%albumin solutions are often administered to increase circulating bloodvolume and to augment intravascular osmotic properties. This method ofretarding CL makes the tenuous assumption that albumin can maintain itsnormally low extravasation rate during shock. Clinical data, however,show that the efficacy of albumin is inconsistent at best (8,9). Somehave even suggested that resuscitation with albumin may increasemortality in critically ill patients (10).

PEGylation has been used extensively (11,12). Modification of interferonbeta-1a with polyethylene glycol prolongs its half-life, resulting inhigher antiviral activity (13). There have been studies on the use ofPEGylated hemoglobin (PEG-Hb) as a substitute for blood (14,15,16).Large amounts of PEG-Hb, constituting up to 80% vascular volume showedthat PEG-Hb is effective in maintaining the hemodynamics and oxygendelivery in the rat (17). These studies suggest that PEG-Hb is safe evenat very high doses.

Other colloids have been used to treat capillary leak conditions withvarying degrees of efficacy. A variety of heterogeneous (M_(r) weightedaverage: 125,000-450,000 Da) starch colloids have been proposed or arein use as substitute for albumin (18). While these compounds are lessexpensive and more readily available than pooled human albumin, use ofstarch colloids has been restricted to low doses due to safety issuesthat severely limit their use. In addition, the high M_(r) (>1,000,000Da) moieties within the heterogeneous starch colloids can alter bloodrheological properties and cause coagulopathy (19). The relativelyhomogeneous Pentastarch (M_(r)=110,000) has been shown to attenuate lunginjury in an aortic occlusion reperfusion injury model (20).

In a recent study, MAP and heart rate (HR) did not change favorably whenhetastarch (HES) was given in a septic pre-treatment rat model (21). Incontrast, favorable changes in MAP (increased) and HR (decreased) wereobserved in rats pre-treated with polymerized hemoglobin. This occurreddespite the fact that, at the same molar concentrations, the colloidosmotic pressure of HES (27 mm/Hg) was higher than the polymerizedhemoglobin (21 mm/Hg). Use of the latter as a routine plasma expander ishowever controversial and is complicated by potential side effectsparticularly in relation to the kidneys.

Finally, several studies have suggested that albumin has an endothelialanti-apoptotic effect by mediating regulation of cellular glutathioneand nuclear Factor Kappa B activation (22,23,24). This may play asignificant role in sepsis induced CL particularly in light of a recentreport that linked CL in different systemic inflammatory responsemanifestations to endothelial cell apoptosis (25).

The available albumin today has a molecular weight of 69,000 with a veryshort half-life (4-6 hours) which can easily leak to the extravascularspace in capillary leak conditions such as severe sepsis, pancreatitis,burn and trauma. This leaking can cause worsening edema and/orcompartment syndrome. The use of pentastarch and hexastarch are oflimited value since they are not for use in pediatric patients and cancause bleeding. Additionally, only 15 cc/kg can be used in patients.Further, the pentastarch and hexastarch have been shown to causeintractable pruritus (itching) after use and the effect lasted foryears. In fact, some studies state that the use of albumin as areplacement or as a volume expander is counterproductive since itincreases edema by drawing fluid out of the capillaries.

Therefore, there is a great need for a composition and a method toeffectively prevent and/or treat hypovolemic conditions which does nothave the above-described disadvantages.

In particular, it is to be noted that Hemorrhagic shock (HS) is aleading cause of death following trauma (1a-3a). Early managementrequires, in addition to controlling the hemorrhage, providing fluidtherapy to restore tissue perfusion. The choice of initial fluid therapycan have a significant impact on the outcome. After hemorrhagic shockand resuscitation, nuclear factor-κB (NF-κB) is activated, triggering aninflammatory response, characterized by overproduction of cytokines suchas TNF-α, chemokines and cell adhesion molecules which activateendothelial cells (EC), macrophages, neutrophils and other cells (4a).These activated cells (5a, 6a) generate oxidation products such asreactive oxygen species (ROS) which cause vascular damage and capillaryleak (CL) (7a-10a). Oxidants and free radicals produced followingreperfusion are potent inducers of apoptosis (11a), especially of theEC. Shrinkage of these cells worsens the widening of theinter-endothelial cell gaps and exacerbates the capillary leak (12a)leading to albumin loss. In this environment of oxidative stress withlow levels of albumin, endothelial integrity is compromised(32a,34a,35a). Oxidation products, cytokines and vascular depletion,worsened by CL, contribute to vascular unresponsiveness to intrinsic andextrinsic pressors (10a, 13a, 14). These events are summarized in FIG.11.

In another area of note, recent studies indicate that the type of fluidused in hemorrhagic shock resuscitation affects the physiologicresponse, the immune response and the systemic inflammatory state.

Crystalloids—Lactated Ringer's (LR) and artificial (synthetic) colloidsactivate neutrophils and up-regulate cell adhesion molecules; theseeffects are not seen with albumin or fresh whole blood (10a,11a).Moreover, animals resuscitated with LR or artificial colloids developedsignificant apoptosis, especially in the lungs and spleen (15a, 16a).Aggressive high volume resuscitation, without controlling the bleeding,can exacerbate the hemorrhage by disrupting the early formed softthrombi, and by diluting coagulation factors (17a). Conversely, smallvolume resuscitation using hypertonic saline (7.5%, HTS) alone or incombination with a synthetic colloid is superior to high volumeresuscitation, especially in head trauma and in patients at increasedrisk for developing abdominal or extremity compartment syndrome.However, adverse effects have been reported with small volume HTS usedalone or in combination with a synthetic colloid, includinghyperchloremic acidosis (18a), and anaphylactoid reactions linked to thecolloid component (19a). Other fluids in preclinical testing, such aslactate ethyl pyruvate and ketone based fluids, show less cellularinjury and better survival in hemorrhaged animals compared to LR (20a,21a).

Colloids—The efficacy and safety of colloid plasma expanders, includingalbumin, are controversial (22a, 23a). Artificial colloids, includingstarches (24a), have been substituted for albumin in treating capillaryleak conditions with varying efficacy. While less expensive and morereadily available than human albumin, starch colloids are restricted tolow doses because the high M_(r) (>1,000,000) components alter bloodrheological properties and cause coagulopathy (23a). In contrast toalbumin, synthetic colloids activate inflammatory and apoptoticprocesses (25a). Albumin does not increase expression of neutrophiladhesion molecule CD-18, an important step in reperfusion injury, whileartificial colloids do (26a). Albumin, which accounts for 80% of bloodcolloid osmotic pressure (27a), extravasates at a low physiologic rate(28a). In patients with CL, 5% or 25% albumin solutions are administeredto increase blood volume and to maintain the oncotic gradient. Theefficacy of albumin treatment is variable (29a) and some studiesindicate that albumin resuscitation may actually increase mortality(30a). However, a recent randomized double blind controlled clinicalstudy in New Zealand and Australia, involving more than 7000 traumapatients receiving normal saline or 4% albumin, showed no difference in28 day mortality between the two groups (31a), (study presented by Dr S.Finfer at the 33 rd Congress of Society of Critical Care Medicine,February 2004, Orlando, Fla.).

Albumin as an anti-apoptotic and anti-inflammatory agent—In spite of theconflicting studies of the clinical efficacy of albumin resuscitation, anumber of lines of evidence indicate that albumin maintains theintegrity of the vascular endothelium (32a-34a) by filling hydrophilicpores of the endothelial surface layer, contributing to their stability(35a). Studies employing human tissue explants in rat skin (36a, 37a)indicate that albumin inhibits endothelial cell apoptosis. Albumin actsas a source of thiol groups (Cys-34); this effect has been demonstratedin septic patients with increases in overall thiol concentration of upto 50% following administration of 200 ml 20% albumin (38a). In vitromechanistic studies showed that albumin exerts its endothelialanti-apoptotic effect by regulating cellular glutathione and NF-κBdeactivation. Physiological concentrations of albumin inhibit TNFαinduction by inhibiting NF-κB activation (39a). In a rodent model of HS,25% albumin resuscitation diminished NF-κB translocation andcytokine-induced neutrophil chemoattractant messenger RNA concentrations(40a).

However, it is also to be noted that is albumin is ineffective inhemorrhagic shock. The ineffectiveness of unmodified albumin as a plasmaexpander in the previous studies (27a, 29a, 30a) may be linked to theseverity of the underlying endothelial cell injury. If the endothelialintegrity is compromised such that albumin can readily extravasate, theleaking albumin may exacerbate the oncotic gradient favoring capillaryleak (41a).

SUMMARY OF THE INVENTION

One aspect of the present invention relates to a composition comprisingan albumin-based colloid composition. In one aspect, the albumin-basedcolloid composition is modified such that its hydrodynamic radius issufficiently large to preclude its leaking through the capillaries whileretaining its oncotic properties and its ability to bind ligands such assodium ions, fatty acids, drugs and bilirubin. While a number ofproteins have been modified with polyethylene glycol, attached throughthe ε-amino group of lysine, without loss of biological activity andwithout significant toxicity, no one has before modified human albuminwith a PEGylation product (including polyethylene oxide) at multiplesites on the albumin protein. The present invention contemplates the useof PEGylation products which expand the composition's hydrodynamic ratioto a degree such that, when administered to a patient in danger of, orsuffering from a hypovolemic state, the albumin-based colloidcomposition reverses the hypovolemic condition.

The albumin-based colloid composition of the present invention isespecially useful for volume expansion in states of shock such as severesepsis, shock, pancreatitis, burn and trauma, thereby improving survivalrates in those conditions.

The albumin-based colloid composition is also useful as a hyperosmoticagent driving, or causing, ultra filtration in peritoneal dialysis.Still other uses include, for example, use in head trauma,hyperviscosity states, patients with liver cirrhosis followingparcenthesis, eukopheresis, nutritional albumin deficiency, nephroticsyndrome, liver failure, severe hypoalbuminemic patients, and severeburn patients.

In one aspect, the present invention comprises a composition of analbumin-based colloid composition having a preferred degree ofhydration. The present invention further relates to two methods toproduce the albumin-based colloid composition by modifying the albuminwith polyethylene oxide: one is by using N-hydroxysuccinamide esters andthe other is by using cyanuric chloride derivatives. The albumin-basedcolloid composition of the present invention is safe and has an extendeduseful half-life. The albumin-based colloid composition can besynthesized using recombinant albumin which decreases itsimmunogenicity.

The albumin-based colloid composition has a lessened tendency toextravascate because of its larger size, thereby avoiding worsening ofthe hypovolemic condition such as capillary leak syndrome andclinically, edema and compartment syndrome.

In another aspect, the volume-expanding properties of the albumin-basedcolloid (or example, albumin with covalently attached polyethyleneglycol (PEG-Alb) is a large albumin-based colloid composition which hasa greater degree of hydration and a larger hydrodynamic radius. Thealbumin-based colloid composition is less likely to enter the extravascular space than normal albumin. Additionally, the albumin-basedcolloid composition retains the important physiologic functions ofalbumin, including roles as an osmolyte, as an antioxidant, and as atransporter of less soluble metabolites such as heme and bilirubin; thelatter two features are not associated with other crystalloids andcolloids.

In one aspect, the present invention relates to a composition comprisinga large albumin-based colloid with a preferred degree of hydration. Thecomposition is an albumin-based colloid and, in one embodiment,comprises a polyethylene glycol modified albumin having a hydrodynamicradius sufficiently large to preclude the molecule from leaking througha patient's capillaries. In certain embodiments, the albumin-basedcolloid composition has a molecular weight of at least about 80 to about250 KD or greater. The composition can comprise human albumin, bovineserum albumin, lactalbumin, or ovalbumin.

The albumin-based colloid composition has an ability to bind ligandssuch as sodium ions, fatty acids, bilirubin and therapeutic drugs.

In another aspect, the present invention relates to an in vivo method ofpreventing or treating hypovolemic conditions comprising administering atherapeutic amount of the large albumin-based colloid composition to apatient in danger of developing such conditions.

In another aspect, the present invention relates to a method for theprevention of mammalian tissue injured or at risk of injury comprisingthe administration of a therapeutic amount to a mammal of a compositioncomprising an albumin-based colloid. The composition is incapable ofleaking through the mammal's capillaries and is present in an amount ofsufficient to protect the tissue from injury. The method is especiallyuseful where the risk of injury is due to hypovolemia, sepsis, shock,burn, trauma, surgery, predisposition to capillary leak, hyperviscositystress, hypoalbuminemia, and/or anoxia.

Yet another aspect of the present invention relates to a method forforming an albumin-based colloid composition which comprises modifyingalbumin with polyethylene oxide. The albumin is modified by usingN-hydroxysuccinamide esters, or, alternatively, is modified by usingcyanuric-chloride derivatives. In certain embodiments, the methodincludes dissolving albumin in potassium phosphate to form an albuminsolution, activating methoxy polyethylene glycol with cyanuric chlorideand dissolving in water to form a methoxy polyethylene glycol solution,adding the methoxy polyethylene glycol solution to the albumin solutionto form a mixture, stirring the mixture for a suitable time at aboutroom temperature, dialyzing the mixture against a phosphate bufferedsaline solution at about 4° C. for a suitable time, and collectingpolyethylene glycol modified albumin. In certain embodiments, the ratioof a volume of the methyoxy glycol solution to a volume of the albuminsolution is in the range of about 1 to about 3.

In a cecal ligation and puncture (CLP) and endoxtoxemic rat models,superior (2-3 hours) fluid resuscitation properties of albumin whenconjugated at multiple sites with methoxy polyethylene (PEG-Alb)compared to either unmodified albumin or crystalloid. The larger PEG-Alb(about 16 times albumin size) and its enhanced colloid osmotic propertylead to less extraveasation under sepsis—capillary leak (CL) conditions.Consequently, PEG-Alb treated rats showed improved blood pressurerecovery and less CL-induced hemoconcentration. In addition inendotoxemic rats, there is evidence of less lung tissue injury withPEG-Alb. PEG-ylation of proteins increases their intravascular retentiontime (half-life) possibly by reducing physiologic turnover (e.g.,protecting against proteolysis) and antigenicity. This inventiondescribes and verifies a method that 1) allows for the simultaneous(i.e., in same subject) assessment of albumin and PEG-Alb intravascularretention times, and 2) provides visualization of extravascular (orleaked) albumin and PEG-Alb as a measure of vital organ injury. Thismethod is based on a double chromophore technique where albumin andPEG-Alb tagged by spectroscopically distinct chromophores and theirconcentrations are repeated assess over time. The albumin is modifiedwith an indicator reagent.

More specifically, the methods of this invention relates to thepreparation of dye conjugated albumin and PEG-Alb. Human albumin (50mg/ml) was incubated 1 hr in 50 mM potassium phosphate (pH 7.5), 150 mMNaCl, and 0.5 mM dithiothreitol. The dithiothreitol-treated albumin wasincubated two hours with 4 mM 5-iodoacetamidofluorescein or 1.5 mM TexasRed maleimide (Molecular Probes). The dyemodified albumins were dilutedfive-fold and reconcentrated three times in a centrifugal concentrator(10,000 Mr cut off, Millipore) to remove most of the unincorporated dye,followed by dialysis for 48 hours against four changes ofphosphate-buffered saline.

DESCRIPTION OF THE FIGURES

The patent or application file contains at least one drawing executed incolor. Copies of this patent or patent application publication withcolor drawing(s) will be provided by the Office upon request and paymentof the necessary fee.

FIG. 1A is a graph showing change in hematocrit (%) for the saline,albumin and PEGA groups.

FIG. 1B shows the correlation of mean arterial pressure with hematocrit.

FIG. 2 is a graph showing changes in blood pressure (i.e., mean arterialpressure MAP) (Normalized P_(art)) immediately after injection ofendotoxin (ET), two hours post injection of ET, and three hours postinjection of ET.

FIGS. 3A-D show the typical histopathologic changes seen in thedifferent treatment groups.

FIG. 4 shows the acute respiratory distress syndrome (ARDS) score ofeach treatment group.

FIG. 5 (Right) shows SDS acrylamide gel electrophoreses showing thatestimated MW of PEG-Alb is ≧250,000 Daltons. Analytical Gel filtrationof PEG-Alb showing samples of albumin, PEG-Alb and standard proteinswere chromatographed on Superose 6. The Insert shows vertical arrowswith letters indicate the elution position of standard proteins: α, α2macroglobulin (720,000); thyroglobulin (660,000 M_(r)); F, appoferritin(440,000); A₂, albumin dimer (133,000); G, IgG (160,000); O, ovalbumin(45,000); M, myoglobin (17,000). FIG. 5 (Left) the results are presentedas V_(e)/V₀ vs M_(r); Upward vertical arrows with numbers correspond toapproximate elution positions indicated by arrows.

FIG. 6 shows SELDI Mass spectrometry of PEG-Alb and albumin. FIG. 6Ashows the analysis of 16 pmoles of human albumin. FIG. 6B shows theanalysis of 15 pmoles of PEG-Alb.

FIG. 7 shows osmotic pressure of PEG-Alb and albumin solutions. Theosmotic pressure of solutions of albumin and PEG-Alb were determined asdescribed below and plotted as osmotic pressure (in mm Hg) versusconcentration. The line corresponds to a fit to a third orderpolynomial.

FIGS. 8A-E shows fluorescent pictures showing: A and B, normal animals,no sepsis, there is localized FI-labeled PEG-Alb within thealveolo-capillary membrane, while B, shows an overlap of the Rh-labeledAlbumin and FI-labeled PEG-Alb appearing yellow (green & red). While inanimals with sepsis (C, D, E), there is a diffuse distribution of theRh-labeled albumin and there is a pattern of concentration of thePEG-Alb at the alveob-capillary membrane.

FIG. 9 shows the purification of PEG-20,000 (maleimide) modifiedalbumin—Human albumin modified with maleimide PEG 20,000 (7 mg ofprotein) was applied to Q-Sepharose (1.5 cm×5 cm) equilibrated in 50 mMTris-Cl (pH 7.5 at 25° C.).

FIG. 10 shows the purification of PEG-40,000 (maleimide) modifiedalbumin—Human albumin modified with maleimide PEG 40,000 (60 mg ofprotein) was applied to Q-Sepharose (1.5 cm×15 cm) equilibrated in 50 mMTris-Cl (pH 7.5 at 25° C.

FIG. 11 is a schematic illustration if ischemia/reperfusion damageleading to apoptosis and capillary leak.

FIG. 12 shows the PEG-Alb the structure of albumin is shown with lysylresidues indicated in green, Cys 34 in red and PEG shown schematically.

FIG. 13 shows the proposed effects of PEG-Alb on oxidation andinflammation cascades.

FIG. 14 shows the effect of Albumin (open circles), PEG-Alb (closedcircles), saline (open squares) and PEG+albumin (closed squares) on meanarterial blood pressure (MAP) in CLP rats.

FIG. 15 shows time course of PEG appearance and elimination in serum andurine.

FIGS. 16A and B shows fluorescence micrographs of lung tissue fromcontrol rat (FIG. 16A) and CLP rat (FIG. 16B). Animals receivedfluoresein labeled PEG-Alb and Texas red labeled albumin.

FIGS. 17A and B show 20X H&E representative lung histological sectionsof LPS-treated rats; FIG. 17 a, Mild (0-1); FIG. 17 b, Moderate (1-2);FIG. 17 c Severe (3-4).

FIG. 18 shows blood pressure HS rats following treatment. Upper curvesolid circles, PEG-Alb; middle curve open circles, albumin; bottom curveopen squares, saline.

FIG. 18A is Table I which shows the Hematocrit (Htc) and Colloid OsmoticPressure (COP) in Hemorrhagic Shock Rats, where Data mean±SD. *=p<0.05;**=p<0.01 where comparisons for all groups are relative to thecorresponding treatment end treatment compared to before treatmentvalues via paired t-tests; a) Before treatment and after treatment,within same group; b) Between Saline and Albumin; c) Between Saline andPEG-Alb; d) Between Albumin and PEG-Alb; (NS) not significant.

FIG. 19 shows a hemorrhagic shock model (phases I & II) where thenumbers below correspond to minutes after hemorrhage.

FIG. 20 shows the dependence of colloid osmotic pressure (solid circles)and viscosity (open circles) on PEG-Alb concentration.

FIG. 21 shows the analysis of mPEG5000 modified albumin (PEGA, solidline) and albumin (HAS, dashed line) by Superose 6 HPLC. Standardseluting at positions indicated by arrows are: α, α-2-macroglobulin; T,thyroglobulin; F, ferritin; G, IgG; O, ovalbumin; and M, myoglobin.

FIG. 22 shows the analysis of mPEG5000 modified albumin (PEGA) sizefractions (indicated as I, II and III) and unfractionated material(indicated by U) by Superose 6 HPLC. Size standards are the same as inFIG. 11.

FIG. 23 shows purification of mPEG-40,000 modified albumin—HSA modifiedwith maleimide mPEG40000 was applied to Q-Sepharose and eluted with agradient of NaCl from 0 to 0.3 M. Inset: results of SDS gelelectrophoresis on successive fractions starting with 31. Lane A in gelis unmodified albumin.

FIG. 24 shows the analysis of mPEG40000 (40) and mPEG20000 (20) modifiedalbumin and albumin by Superose 6 HPLC. Standards are the same as inFIG. 11.

FIGS. 25A and 25 B show urea unfolding of albumin (FIG. 25A), mPEG20000albumin (FIG. 25B) and mPEG40000 albumin (FIG. 25C). Samples (0.05 mg/mlalbumin in 10 mM KP_(I) (pH 7.4), 150 mM NaCl) were incubated for 12hours at the indicated [urea] prior to collecting emission spectra.Emission from 310 to 370 nm was measured with excitation at 295 nm andthe result plotted as intensity averaged emission wavelength (<λ>_(IE)).Solid lines correspond to a fit to a three-state unfolding model.

FIG. 26 shows DSC scans of PEG40-Alb (PEGA40) and unmodified albumin(HSA).

FIG. 27 shows quenching studies of PEG modified albumins. A: acrylamidequenching of albumin and size fractionated mPEG5000 albumin; B: KIquenching of albumin and size fractionated mPEG5000 albumin; C:acrylamide quenching of albumin, mPEG20000 albumin and PEG40000 albumin.Solid lines are fits of the Stern-Volmer equation with static quenching.

FIG. 28 shows the osmotic pressure of PEG-modified albumins—Osmoticpressure of solutions of unmodified albumin, albumin modified withmPEG20000 (PEGA20) or mPEG40000 (PEGA40) maleimides and albumin modifiedwith unfractionated mPEG5000 (PEGA5) was measured at the indicatedconcentrations at 22° C. Lines are fits of a third order polynomial.

FIG. 29 shows the structures of reactive mPEG reagents.

FIGS. 30A and 30B show unfolding of unmodified human albumin andmPEG5000 modified albumin. FIG. 30A: unfolding of unmodified humanalbumin monitored by CD. FIG. 30B: unfolding of mPEG5000 modified humanalbumin monitored by CD. Differences in scales reflect different proteinconcentration.

FIGS. 31A and 31B show fluorescence data (log-scale) indexed to theconcentration at injection time.

FIGS. 32A and 32B show fluorescence data (log-scale) indexed to theconcentration at injection time.

FIG. 33 shows PEG-Alb/albumin fluorescence data indexed to theconcentration at injection time (Time=0) as a function of time forindividual normal & CLP rats.

DESCRIPTION OF THE PREFERRED EMBODIMENTS

According to one aspect of the present invention, unlike starches, thealbumin-based colloid composition retains the important physiologicfunctions of albumin, including roles as an osmolyte, as an antioxidant(26), and as a transporter of less soluble metabolites such as heme andbilirubin (27); the latter two features are not associated with othercrystalloids and colloids. Protein unfolding studies performed onPEG-Alb indicated that albumin functionality is highly preserved).

According to the present invention, the colloid oncotic properties ofthe albumin-based colloid composition are superior to those ofunmodified albumin with regard to plasma volume expansion duringtreatment of hypovolemic. The albumin-base colloid composition reducesthe likelihood of end organ injury, and hence morbidity and mortality,in critically ill patients. The present invention also relates to amethod for the pretreatment of septic patients to prevent or ameliorateARDS and maintain blood pressure. The albumin-based colloid compositionof the present invention, with its larger molecular weight (preferablyabout 80 KD or greater) and augmented colloid osmotic function, isvastly superior to saline or albumin with regard to improving thephysiological and histologic manifestations of endotoxin-induced shock.

The albumin-based colloid composition is kept in the intravascularcompartment in patients, even in sepsis conditions where capillary leakoccurs. In the lipopolysaccharide (LPS) induced model of sepsis in rats,there was no difference in hematocrit (HCT) pre-experiment, howeverafter inducing sepsis, the hematocrit of the saline and albumin treatedgroups increased while that of the PEG-Alb group decreased. FIG. 1 showsthe positive difference in the post-pre hematocrit in groups 1 and 2while there is a negative difference in the post-pre hematocrit of group3 (PEG-Alb group). The data also shows that albumin tends not to bedifferent with respect to hemoconcentration as well as loss of fluidinto the interstitial space.

The maintenance of blood pressures in sepsis is also important. Theefficacy of PEG-Alb, saline and albumin treatments for prevention ofsepsis induced hypotension are shown in FIG. 2. At 2 and 3 hours afterLPS (lippopolysaccharide), MAP (mean arterial pressure) was decreasedcompared to baseline values in both albumin and saline treated groups.Alternatively, the average response in PEG-Alb rats was unchanged atboth times. Changes in MAP after LPS showed noticeable variability evenwithin treatment groups. Nevertheless, the increased efficacy of PEG-Albin maintaining MAP was statistically significant (two-way repeatedmeasures ANOVA; P=0.023).

The histopathologic findings clearly show that the PEG-Alb treated groupexhibits less alveolar damage than the albumin group. (FIGS. 3A-D). Lunginjury (acute respiratory distress syndrome (ARDS) was significantlyless (one-way ANOVA; P-0.002) in PEGA treated rats compared to bothalbumin and saline treated rats, as shown in FIG. 4. Given the minimalinfiltrates and hyalinization in the lung tissues of PEG-Alb ratscompared to the positive controls and albumin treated rats, PEG-Albtreatment is better than albumin in LPS-induced hypovolemia.

FIG. 5 (Left) shows the SDS-Acrylamide gel electrophoresis of PEG-Alb.

Lanes 1 and 4 contain standard markers which are from top to bottom: 1)Myosin (MW 205 KD); 2) Phosphorylase (97 KD); and 3) Bovine serumalbumin (66 KD). Lanes 2 contains human serum albumin after pegylationand its molecular weight over 200 KD. Lane 3 contains human serumalbumin before pegylation.

FIG. 5 (Right) shows the gel filtration of PEG-Alb on Superdex S200-PEGAsize standards was applied to Superdex equilibrated in 10 nM KPO₄, 150nM NaCl. Standards indicated are thyroglobulin (Thyr), immunoglobulin(IgG), albumin (alb), ovalbumin (OVAL) and Myoglobin (My). Peg-albumineluted as two weeks: Peak I was the void volume and Peak II eluted afterthyroglobulin.

According to the present invention, pretreatment of rats with PEG-Albprior to induction of sepsis with LPS dramatically reduces themanifestations of LPS-induced shock when compared to pretreatment ofanimals with saline or unmodified albumin. High dose of LPS was givenbecause rodents are relatively resistant to LPS, and sustainedhypotension is needed to simulate the severe human sepsis with MODS.PEG-Alb gives a more rapid recovery in blood pressure, a lowerhematocrit—suggesting hemodilution as opposed to the hemoconcentrationthat characterizes CL—and significantly reduced lung injury. The largereffective size of the PEG-Alb molecule renders it less likely toextravasate in the presence of cell injury and during a loss ofendothelial integrity.

The shock that follows administration of an endotoxin is characterizedby a biphasic blood pressure response. In the first phase, a drop inblood pressure occurs 10-15 minutes after LPS is injected. This wasevident in all of the LPS-injected animals, suggesting that PEG-Alb doesnot act by neutralizing the endotoxin itself. The second phase ofhypotension is caused predominantly by the action of inducible nitricoxide (iNOS), which substantially reduces plasma volume (28). It isduring this second phase that PEG-Alb has a superior effect whencompared with albumin or saline. Although iNOS m RNA or peptide was notmeasured, it is very likely under these conditions employed here; i.e.,intravenous administration of 20 mg/Kg LPS that iNOS was induced. Whileinherent limitations exist with any pretreatment model, the data showthat administering PEG-Alb prior to LPS protects rats from developingARDS.

The hematocrit, mean arterial pressure, and histology all indicate thatPEG-Alb is a beneficial treatment for the LPS-induced hypovolemia. Boththe hemodilution and the unchanged MAP achieved with the PEG-Albtreatments are indicative of plasma volume expansion (or at leastmaintenance), while the opposite effects were observed with both albuminand saline. Maintenance of intravascular volume with PEG-Alb isconsistent with reduced capillary leak. Histopathologic findings (FIGS.3A-D) show minimal interstitial infiltrates and hyalinization in thelung tissues of PEG-Alb-treated rats. Immunflourescence studies showthat PEG-Alb tends to be retained in the vascular space to a greaterextent than albumin during capillary leak (FIG. 3).

The improved colloidal properties of PEG-Alb result from increasedhydrophilic properties, which are shown by its very large hydrodynamicradius—as reflected in its behavior on a gel filtration column and itslarger molecular radius of gyration (R_(G)) and excluded volume (Λ) asinferred from its nonideal osmotic properties. This was alsodemonstrated using size exclusion chromatography where the elution ratioof PEG-Alb/albumin agreed with the excluded volume of PEG-Alb/albumin(FIG. 5) using colloid osmometry. Similarly increased R_(G) and Λ ofproteins after modification with covalent bonding with one or more PEGgroups were previously reported in case of bovine hemoglobin by Winslowand colleagues (29).

The colloid oncotic properties of PEG-Alb are superior to those ofunmodified albumin with regard to plasma volume expansion duringtreatment of hypovolemia associated with CL. PEG-Alb is useful to reducethe likelihood of end organ injury, and hence morbidity and mortality,in critically ill patients. The present invention is useful in thepretreatment of patients to prevent or ameliorate ARDS and maintainblood pressure. PEG-Alb, with its larger molecular weight and augmentedcolloid osmotic function, is vastly superior to saline or albumin withregard to improving the physiological and histologic manifestations ofendotoxin-induced shock.

The following examples are provided merely to further illustrate thepresent invention. The scope of the invention shall not be construed asmerely consisting of the following examples.

EXAMPLE I Use of Polyethylene Glycol Modified Albumin (PEG-Alb) inSepsis

Materials and Methods: Preparation of PEG-Alb. 2 gms of human albumin(Sigma, St. Louis, Mo.) was dissolved in 45 ml. of 50 MM of potassiumphosphate (mixture of mono and dibasic), pH 7.4. 500 mg of methoxypolyethylene glycol (Sigma, St. Louis, Mo.) was activated with cyanuricchloride and dissolved in 4 ml. of water. 1.4 ml of methoxy polyethyleneglycol solution was added to 45 ml of the human albumin solution and themixture was stirred for two hours at room temperature. The mixture wastransferred to a dialysing tube (molecular weight cut off—12500) anddialysed against 3000 ml of phosphate buffered saline at 4° C. for 72hours. The polyethylene gylcol modified albumin (PEGA) was collected andthen frozen at −20° C. until its use.

Animals. Adult male Sprague-Dawley rats (Charles River Laboratories,Portage, Mich.) weighing 400-480 grams were used. Animals were housed inan American Association for Accreditation of Laboratory Animal Care,International (AAALACI) approved facility. They were provided standardrat chow and water ad libitum. All protocols were approved by theInstitutional Animal Care and Use Committee and the ABC (Hazard)Committee.

Methods

The animals were fasted overnight, but given water ad libitum. Animalswere anesthesized using Sodium pentobaribital (50 mg/kg)intraperitoneally and given additional doses as needed during the courseof the experiment. An arterial cathether (Intramedic PE-50, Clay Adams)was placed on the carotid artery and hooked to the transducer/amplifierfor continuous blood pressure monitoring (TestPoint, Capital EquipmentCorporation, Billerica, Mass.). An intravenous line was placed on theopposite internal jugular vein using G24 cathether. A blood sample wastaken from the carotid line for baseline hematocrit and albumin andreplacement fluid (1 ml 0.9% saline) was infused via the intravenousline. Normal saline 5 ml was infused in group 1. Albumin 0.6 gms/kg bodyweight (BW) was given to group 2 and PEGA 0.6 gms/kg BW was given togroup 3. After 30 minutes, endotoxin (LPS) (Sigma Chemicals, St. Louis,Mo.) was given to the three groups at varying doses. The rats weredivided into 3 groups based on the received resuscitation fluid: Group 1(n=9) received unmodified albumin in normal saline solution at a 0.6gm/kg dosage; the injection concentration of albumin was 40 mg/ml,yielding an injection volume of 1.5 ml/100 g body weight (BW). Insteadof albumin, Group 2 (n=12) received PEG-Alb at the same dosage, proteinconcentration, and injection volume as at Group 1. Group 3 (n=6)received 1.5 ml/100 gm BW of normal saline. Blood pressure monitoringwas done for three hours after endotoxin infusion after which the ratswere euthanized.

Post-experiment blood samples for hematocrit and albumin were taken. Theright lung was put in formalin and set to pathology for hematoylin-eosinstaining.

PEG-modified albumin (PEG-Alb) was examined as a potential plasma volumeexpander. Albumin modified at multiple sites, exhibited a largereffective molar volume and exerted greater osmotic pressure thanunmodified albumin. Solutions of PEG-Alb, albumin, and saline weretested in a rat endotoxin-induced model of shock. Pretreatment withpolyethylene glycol modified-human albumin (PEG-Alb) maintained meanarterial pressure (p=0.023), retained volume as evidenced byhemodilution (p=0.001) and attenuated the histologic manifestations ofacute respiratory distress syndrome (ARDS) (p=0.002). Rats werepretreated with fluorescence labeled PEG-Alb and rhodamine labeledalbumin, separately and in combination, followed by treatment with LPS.Fluorescence microscopy of lung sections indicated thatfluorescence-labeled PEG-Alb was retained within the blood vesselsrhodamine-labeled albumin was not. Compared with the use of saline orunmodified human albumin, PEG-Alb is a useful alternative plasma volumeexpander that may be of use in hypovolemic states.

EXAMPLE II Use of PEG-Alb to Restore Vascular Volumes and AttenuateAcute Lung Injury in Endotoxin-Induced Shock

Preparation of Albumin and PEGA (PEG-Alb)

Methoxypolyethylene glycol cyanuric chloride (average M_(r) 5000) wasadded to human albumin (type V, Sigma Chemical Co.) dissolved in 50 mMKP_(I) (pH 7.5) at 50 to 60 mg/ml with gentle stirring four times (0.2mg per mg of albumin per addition) at 10-minute intervals at 22° C. Thereaction was allowed to stir 40 minutes after the last addition of thereagent. Modification was rapid, being complete in less than 15 minutesat room temperature with the extent of modification depending primarilyon the amount of reagent added. Prior to infusion into animals, bothalbumin and PEG-Alb were dialyzed against phosphate-buffered saline for48 hours with three changes of buffer using high-molecular-weight-cutoffdialysis tubing (50 kDa molecular mass cutoff).

FITC-Albumin and FITC-PEG-Alb

Human albumin (50 mg/ml) was incubated 1 hr in 50 mM KP_(i) (pH 7.5),150 mM NaCl, and 0.5 mM dithiothreitol. The dithiothreitol-treatedalbumin was incubated two hours with 4 mM 5-iodoacetamido fluorescein or1.5 mM tetramethylrhodamine-5-iodoacetamide. The flourescein-modifiedalbumin was dialyzed 48 hours against four changes of phosphate-bufferedsaline to remove free flourescein. Rhodamine-labeled albumin waschromatographed on Sephadex 50 followed by extensive dialysis againstphosphate-buffered saline.

Some of the flourescein-labeled albumin was modified withmethoxypolyethylene glycol cyanuric chloride and purified by gelfiltration on Sephacryl S200. Fractions from Sephacryl S200 eluting withapparent molecular weights in excess of 200,000 were pooled andconcentrated using an Amicon ultrafiltration cell with a PM10 membrane.Analysis of the flourescein and rhodamine-labeled albumins by gelelectrophoresis revealed that the fluorescence was associated with theprotein; no fluorescence was detected at the positions of freeflourescein or rhodamine.

Physiological Studies

Experimental protocols were approved by the Institutional Animal Careand Use Committee (IACUC) and the Academic Chemical Hazardous Committee(ACHC) at the Medical College of Ohio. Adult male Sprague-Dawley rats(Charles River Laboratories, Portage, Mich.) weighing 400-480 grams wereused. Animals were housed in an American Association for Accreditationof Laboratory Animal Care, International (AAALACI) approved facility.They were provided standard rat chow and water ad libitum. Prior to theexperiment, the animals were fasted overnight, but given water adlibitum.

All rats were anesthetized using sodium pentobarbital (50 mg/kg bodyweight) intraperitoneally followed with additional intravenousmaintenance doses at 1 hour intervals. Mean arterial pressure (MAP) wascontinuously measured via a catheter (Intramedic PE-50, Clay Adams)placed in the right carotid artery and attached to a blood pressuretransducer and amplifier (BLPR and TBM4, World Precision Instruments,Sarasota, Fla.) and collected on a computer (TestPoint, CapitalEquipment, Billerica, Mass.). An intravenous line for infusion wasinserted in the left jugular vein (G24 Protectiv*Plus, Johnson andJohnson/Ethicon, Arlington, Tex.).

The rats were divided into 3 groups based on the received resuscitationfluid: Group 1 (n=9) received unmodified albumin in normal salinesolution at a 0.6 gm/kg dosage; the injection concentration of albuminwas 40 mg/ml, yielding an injection volume of 1.5 ml/100 g body weight(BW). Instead of albumin, Group 2 (n=12) received PEG-Alb at the samedosage, protein concentration, and injection volume as at Group 1. Group3 (n=6) received 1.5 ml/100 gm BW of normal saline. A 1 ml baselineblood sample was taken for baseline hematocrit (Hct) measurement fromthe carotid line and replaced with the same volume of 0.9% saline. MAPmonitoring was initiated at the start of the fluid infusion. After 30minutes, 20 mg/kg BW of Endotoxin (E. Coli lipopoly-saccharide [LPS]from serotype 055: B45, Sigma Chemicals, St. Louis Mo.) dissolved in 1ml of saline was administered, and the rats were monitored for 3 hoursthereafter. A blood sample was then taken for post sepsis Hctassessment, and then rats were euthanized with 150 mg/kg/BW ofPentobarbital IP and exsanguinated. Finally, one kidney and the lungswere harvested and immediately fixed in 10% formalin for subsequenthistologic examination.

Histologic Studies

The lung and kidney tissues were removed from formalin solution andsubjected to standard processing, including a hematoxylin and eosinstain. These coded preparations were examined with a light microscope bya blinded pathologist, who scored the inflammatory histopathologicfeatures using the following five-point system: 0=no significanthistopathologic changes; 1=minimal interstitial inflammatoryinfiltrates; 2=mild interstitial inflammatory infiltrates with mildhyalinization; 3=moderate interstitial inflammatory infiltrates withmoderate hyalinization; 4=severe interstitial inflammatory infiltrateswith severe hyalinization. In order to ensure consistency, the samepathologist examined samples on two separate occasions, and the averagedscore was used.

Molecular/Biophysical Studies

SDS Gel Electrophoresis. Samples of unmodified albumin and PEGA wereprepared for electrophoresis by adding SDS (1%, W/V) and betamercaptoethanol (5%, V/V) and heating in a boiling water bath for 1minute. Samples were subjected to electrophoresis on 7.5% or 10%acrylamide gels (30).

Size Exclusion Chromatography

Albumin and PEGA were analyzed by size-exclusion chromatography on a 24ml bed volume Superose 6 column (Pharmacia). Samples or a mixture ofstandards (in 0.5 ml) were applied to the column and eluted with 10 mMpotassium phosphate (pH 7.5) and 150 mM NaCl at 0.5 ml min⁻¹. Absorbanceat 280 nm was monitored continuously.

SELDI-TOF Protein Analysis

Surface-enhanced laser desorption/ionization-time of flight (SELDI-TOF)mass spectrometry was used to characterize the PEG-albumin and albuminsamples. One microliter of sample (at 1 to 5 mg ml⁻¹) was deposited andallowed to air dry directly onto a 2 mm spot of an alaphatically coatedaluminum ProteinChip array (H4 ProteinChip, Ciphergen Biosystems, PaloAlto, Calif.). Twice, one half microliter of energy absorbing matrix(EAM, a saturated solution of 3,5-Dimethoxy-4-hydroxycinnamic acid inaqueous 50% acetonitrile and 0.5% triflouroacetic acid) was applied tothe sample and allowed to air dry.

The ProteinChip array was transferred to a ProteinChip reader and alaser (N2 320 nm-UV) was focused on the sample in a vacuum chamber.After 2 warming laser shots, proteins absorbed to the matrix wereionized and desorbed from the array surface. Ionized proteins weredetected and molecular masses were determined using TOF analysis. TheTOF mass spectra were collected in the positive ion mode with aProteinChip System (PBSII series, Ciphergen) using Ciphergen Peaks(version 2.1b) software. Real-time signal averages of 65 laser shotswere averaged to generate each spectrum.

Colloid Osmotic Pressure (COP)

Both PEGA-Alb and albumin were prepared for COP measurements in similarfashion. Briefly, samples were dissolved in 10 mM potassium phosphate(pH 7.5), 150 mM NaCl at 50 mg ml⁻¹, treated with dithiothreitol (0.5 mMdithiothreitol) for 1 hour at 30° C., and then incubated withiodoacetamide (5 mM iodoacetamide) for 1 hour at 30° C. The acetamidatedalbumin (5 ml at 50 mg ml⁻¹) was then subjected to chromatography onSephacryl S300 (2.8 cm×40 cm) equilibrated in 10 mM potassium phosphate(pH 7.5) and 150 mM NaCl to reduce albumin dimer and other low and highmolecular weight contaminants that otherwise interfere withdetermination of osmotic pressure. Finally, both albumin and PEGA weredialyzed against several changes of 0.9% NaCl.

COP measurements with each colloid were repeated over a wide range ofconcentrations using the Wescor Model 4420 colloid osmometer (Logan,Utah). The instrument was blanked with 0.9% saline and calibrated with a20.2 mOsm albumin standard solution. Note, the concentration ofunmodified albumin was determined from absorbance at 280 nm(ε_(280 nm, 1%)=5.31) (31) and were confirmed by dry weightmeasurements. PEG-Alb concentrations were estimated from dry weightdetermination.

COP [π] in terms of concentration [c] were analyzed via a nonlinearleast squares fit of the equation to estimate 1) estimate the weightedmolecular Mass [Mr] reflected from the ideal component of the π-crelation (32) and 2) the non-ideal contributions of all other virialcoefficients via the two parameters B and α:

This form of the equation is a slight modification yet more flexibleform of the traditionally employed equation [π=RT(c/Mr+Bc²+Cc³ . . . )]that avoids a priori assumptions of number of virial coefficients;R=63.364 mm Hg M⁻, c is concentration (g per dl), and T is temperature(295° K).

Statistical Analysis

The difference between pre and post-LPS hematocrits among these threetreatment groups was compared by ANOVA, whereas two-way repeatedmeasures of ANOVA were used to compare mean arterial pressure (MAP)before LPS and at multiple time points after LPS. Individual differencesbetween groups were assessed using a Tukey multiple-comparison test. Ap<0.05 was used to indicate statistical significance.

Physiological Studies

Vascular volume contraction/expansion following LPS—induced sepsis wasinferred from the changes in MAP and Hct. Both of these measures variedsignificantly for rats pre-treated with PEG-Alb, albumin or saline.Initially, within 15-25 minutes post LPS bolus infusion, all threegroups showed a similar drop of ˜40% in MAP (Saline: 135±11 down to81±30 mmHg; Albumin: 134±14 down to 85±20 mmHg; PEG-Alb: 125±12 down to79±19 mmHg) (FIG. 2). The MAP recovery that followed was significantlybetter in PEG-Alb [MAP [3 hrs after LPS]=120±10 mmHg; p=0.023) treatedrats compared to both saline (99±29 mmHg) and albumin (108±14 mmHg)treatments. MAP recovery was slightly greater in albumin versus salinetreated rats, but this difference was not significant.

Pre-LPS hematocrit was similar in all study groups [44±2 (saline), 42±3(albumin) and 45±2 (PEG-Alb)]. At 3 hours after LPS, hematocrit (post)was elevated relative to baseline (pre) levels for both the albumin (HctRatio (post/pre)=1.09±0.11) and saline (Hct Ratio=1.19±0.09) treatedrats indicating a relative decrease in intravascular fluid volume orhemoconcentration (FIG. 1-A). Conversely, PEG-Alb-treated rats exhibitedhemodilution after LPS administration (Hct Ratio=0.93±0.07). Thesetrends were highly reproducible within each group, and the differencesbetween treatment groups were highly statistically significant (one-wayANOVA; p=0.001). Most importantly, these changes in HCT were generallycorrelated to the extent of MAP recovery as evidenced by the clusteringof the MAP Ratio vs. Hct Ratio (33). Here, PEG-Alb rats generallyexhibited Hct Ratios <1 (i.e., hemodilution) and MAP Ratios at or near 1(i.e., near complete recovery at 3 hours post-LPS). Alternatively, forsaline and albumin treated rats, the post-to-pre MAP Ratios wererelatively lower (incomplete MAP recovery) while Hct Ratios weregenerally >1 (hemoconcentration). FIG. 1(B).

Histologic Studies

Microscopic examination of lung tissue sections taken fromPEG-Alb-treated and control (no-sepsis) rats did not reveal significanthistopathological changes (FIG. 3.A-D). Alternatively, substantialinflammatory histopathologic changes consistent with severe acute lunginjury (ALI), including hyalinization and interstitial lymphocyticinfiltrates, were evident in most saline and albumin treated rats (FIG.3). Overall, the averaged ALI scores (0=No injury; 1=minimal; 2=mild;3=moderate; 4=severe) were significantly lower in PEG-Alb-treated rats(0.76±0.47; range: 0-1) compared to both the saline (2.0±1.0; range:0-3) and albumin (2.4±0.9; range: 1-4) groups (One Way ANOVA; P=0.002).In all four groups, microscopic sections of the kidneys showed nosignificant histopathologic changes.

Results from example normal (FIG. 8.A) and septic (FIG. 8.B) ratsinfused with a mixture of fluorescein-labeled PEG-Alb (green) andrhodamine-labeled albumin (red) exhibited distinctly differentdistribution patterns of the two chromofores. Specifically, thealveolar—capillary area of the normal rats was characterized bylocalized yellow (i.e., red and green) compared to more diffusedistribution of the chlorofores in septic rats particularly the redrhodamine suggesting its extravasation. A consistent finding is alsoevident from septic rats injected with a single colloid species; i.e.,either fluorescein-labeled PEG-Alb (FIG. 8.C) and fluorescein-labeledalbumin (FIG. 8.D). Here too, the Albumin treated septic rats exhibiteddiffuse fluorescence while PEG-Alb treated rats did not.

Biophysical Properties of PEG-Alb

Molecular size—The results of SDS gel electrophoresis of albumin andPEG-Alb are contrasted in FIG. 5A (Right). Expectedly, albumin runs as afairly homogeneous protein and at its known molecular weight. Incontrast, while PEG-Alb ran at higher apparent molecular weights, thePEG-Alb material does not readily enter the gel. Note, in case ofnon-ideal proteins, the electrophoretic mobility is primarily areflection of their extended nature rather than their molecular weight.The substantial heterogeneity of the modified protein is due to PEGmodification at multiple lysyl residues. PEG-Alb was also examined bygel filtration. Consistent with its behavior on SDS gel electrophoresis,the modified protein is substantially heterogeneous, eluting from thecolumn over an apparent M_(r) range from 500,000 to several million FIG.5B (Left). Its behavior on a size-exclusion chromatography (SEC) columnis also a manifestation of the extended nature of attached PEG, notactual molecular weight. Using the Absorbance—V_(e)/V₀ data for bothalbumin and PEG-Alb in FIG. 7, we calculated the corresponding mean VeN₀to be 2.112 and 1.588, respectively. Effective molecular weights (orsize) for the albumin and PEG-Alb in the samples were determined to beabout 77,670 Da and 994,300 Da, respectively, or a relative size ratioof about 12.8. The albumin estimate was greater than the known albuminsize (67,000 Da) falling between its monomer and dimer weights, and thisis consistent with the presence of a two Albumin absorbance peaks—adominant monomer peak and a smaller dimer peak.

To examine the extent of PEG modification by a different technique,albumin and PEGA were analyzed by SELDI-TOF mass spectrometry. Bothspectra showed multiple peaks that resulted from the a) presence ofmonomers and multimers and, more relevantly, b) the detection of singlycharged (z=1) as well as multi-charged (z≧2) species. Accounting forthese effects, the dominant single-charged albumin monomer spectral peakwas centered around a molecular mass of 66,880±2,800 Da (FIG. 6-A). Incontrast, the corresponding PEG-Alb peak was more heterogeneous andexhibited multiple molecular mass species ranging from 77.4 to in excessof 100 kDa separated. These varying PEG-Alb components reflected thenumber of PEG groups attached by modifying lysyl residues per albuminmolecule. Indeed, the mass separation of these PEG-Alb species wasconsistent with the size of the reagent (5000 M_(r) average). The meanmolecular mass of the PEG-Alb monomer predicted from SELDI-TOF was94.000 Da±8.000 Da. This corresponded to an average of five to six PEGgroup attachments per albumin.

Colloid osmotic pressure (π). To evaluate the properties of PEG-Alb asan osmolyte compared to albumin, we examined their osmotic pressure (π)over a wide range of concentrations (g/dL). Both albumin and PEG-Alb,albeit differently, showed nonlinear dependence of osmotic pressure withrespect to protein concentration (FIG. 7) reflecting their colligativeproperties, the Donnan effect, and effects arising from their molecularexcluded volumes (Λ). A fit of these π—concentration data for albumingave a value of 63,300 for the number-averaged molecular weight, a valueof 15.6 for the virial coefficient B, and an α=2.0*. From thesecoefficients, the computed molecular radius of gyration (Rg) and Λ foralbumin were 3.9 nm and 2,070 nm³, respectively. All these estimates arein good agreement to previously published values (34). Theπ—concentration data for the PEG-Alb showed greater non-ideality orincreased curvature compared to albumin. The correspondingnumber-averaged molecular weight of PEG-Alb was 128,000 Da, B=62,α=2.40, Rg=10.0 and Λ=33,378 nm³. The latter corresponded to a 16-foldrelative increase of Λ after modification with PEG. This relative changein the extended nature of the protein with pegylation is comparable tothe 13-fold increase inferred from the SEC measurements on the sameproteins.

The two methods for estimating molecular weight (SELDI and colloidosmometry) provided similar estimates for albumin but not PEG-Alb. Forthe latter, the π-based estimate was greater than expected at 128,000Da. Since the osmotic pressure derivation provides a number averagedmolecular for all species in the solution, then an overestimate ofmolecular weight by this method is consistent with the presence ofmultimers. While not wishing to be bound by theory, it is believed thisis a likely explanation of these apparent differences since the SELDIdata does indeed suggest the presence of PEG-Alb multimers (FIG. 6).

Compared to saline and albumin, pre-treatment of rats with PEG-Alb priorto LPS-induced septic shock resulted in: 1) a more complete recovery inblood pressure, 2) unchanged or slightly lowered hematocrit, suggestinghemodilution as opposed to hemoconcentration that usually characterizesCL, and 3) significantly reduced lung injury.

Since rodents are fairly resistant, a relatively high dose of LPS wasused in the experiments to ensure significant and sustained hypotensionas a way of simulating severe human sepsis with MODS (35). Thehypotension that follows LPS is characterized by a biphasic response. Inthe first phase, a sharp rapid drop in arterial pressure occurs within15-25 minutes of LPS bolus infusion. This phase did not differ among thetreatment groups indicating that albumin and PEG-Alb did not alter theinitial effects of endotoxin relative to saline. The second phase ofhypotension is caused predominantly by the action of inducible nitricoxide (iNOS), which substantially reduces plasma volume via CL (36).While iNOS mRNA or peptide was not measured, it is highly likely thatiNOS was induced by the administration of a high LPS dose (20mg/Kg)(37).

The superior effects of PEG-Alb compared to albumin or saline weremanifested in this second hypotension phase of endotoxin shock. Evidenceof this included the more complete blood pressure recovery and relativehemodilution. Also, minimal interstitial infiltrates and hyalinizationin the lung tissues of PEG-Alb-treated rats were evident from lunghistopathology while immunflourescence studies in lung tissues showedgreater retention of PEG-Alb intravascularly compared to apparentalbumin extravasation in the presence of CL. All these are consistentwith less capillary leak and greater plasma expanding properties.

The in vitro measurements show that the substantially larger effectivesize and greater colloid osmotic pressures of the PEG-Alb molecule,relative to albumin renders, is less likely to extravasate in thepresence of cell injury and loss of endothelial integrity. Indeed, SECand colloid osmometry indicated a 13-16 fold increase in the extendedmolecular structure/excluded volume after pegylation. The improvedcolloidal properties of PEG-Alb resulted from increased hydrophilicproperties, which are reflected by the larger hydrodynamic/gyrationradius (R_(G)) and excluded volumes (Λ). In a canine model of endotoxicshock, the severity of capillary permeability was inferred by themeasurment of different proteins molecular weights by electropheresis(38). The larger molecular weights corresponded to MW of 900,000 Da andthe smallest being the albumin (60,000 Da). The albumin corresponded toa radius of gyration 3.4 nm and Apopferritin dimer, the largest proteinto 12.1 nm, knowing that the larger gaps are far less represented at theendothelium compared to the medium gaps (60,000-500,000 Da) (39),PEG-Alb with its 10. nm size should be retained in the vascular space inmoderate to severe leak.

EXAMPLE III The Synthesis and Purification of Maleimide-PEG Derivativesof Human Albumin were Completed

Human albumin (Sigma Chemical Co. type V) at 50 mg ml-1 in 10 mMpotassium phosphate (pH7.5), 150 mM NaCl, and 0.5 mM dithiothreitol wasincubated for 1 hour at 30° C. Maleimide-methoxypolyethylene glycol20,000 Mr (Shearwater Inc. cat. Number 2D2MOP01) ormaleimide-methoxypolyethylene glycol 40,000 Mr (Shearwater Inc. catnumber 2D2MOP01) was added to 1 mM and the reactions were incubated for1 hour at 30° C. PEG-modified albumins were purified by ion exchangechromatography on Q-Sepharose) Pharmacia).

FIG. 9 shows the purification of PEG-20,000 (maleimide) modifiedalbumin—Human albumin modified with maleimide PEG 20,000 (7 mg ofprotein) was applied to Q-Sepharose (1.5 cm×5 cm) equilibrated in 50 mMTris-Cl (pH 7.5 at 25° C.). The column was eluted at 27 ml/hr andfractions of 1.5 ml were collected. Chromatography was performed at roomtemperature (22° C.). The column was eluted with a gradient of NaCl from0 to 0.5 M (100 ml total volume) starting at fraction 7. Unmodifiedalbumin elutes between fractions 35 and 43. The inset in the Fig. showsthe results of SDS gel electrophoresis (10% acrylamide gel) on alternatefractions starting with 28. The lane labeled A in the gel insetindicates unmodified albumin run as a marker and the position ofmolecular weight markers are indicated at the right of the gel.

FIG. 10 shows the purification of PEG-40,000 (maleimide) modifiedalbumin—Human albumin modified with maleimide PEG 40,000 (60 mg ofprotein) was applied to Q-Sepharose (1.5 cm×15 cm) equilibrated in 50 mMTris-Cl (pH 7.5 at 25° C.). Chromatography was performed at roomtemperature (22° C.). The column was eluted at 27 ml/hr and fractions of4 ml were collected. The column was eluted with a linear gradient ofNaCl (250 ml total volume) from 0 to 0.3 M starting at fraction 15.Unmodified albumin elutes between fractions 45 and 55. The inset in theFig. shows the results of SDS gel electrophoresis (10% acrylamide gel)on successive fractions starting with 31. The lane labeled A in the gelinset indicates unmodified albumin run as a marker and the position ofmolecular weight markers are indicated at the right of the gel.

EXAMPLE IV Administration of a Larger and Functionally Preserved Albumin(PEG-Alb_(cys-34)) Improves Outcomes in Hemorrhagic Shock

In another aspect, the present invention relates to a polyethyleneglycol-modified albumin (PEG-Alb) developed by the inventors herein thatis 16 times larger than albumin (42a); a representation of PEG-Alb isshown in FIG. 11. PEG-ylation, in addition to augmenting the hydrophilicproperties, increases half-life (43a) of proteins in serum and decreasesprotein immunoginecity (44a-46a). Attaching PEG to proteins decreasesthe ability of the immune system (cellular or humoral) to recognize theproteins as a non-self. This stealth effect induced by PEG-ylation issecondary to the excluded volume effect resulting from the polymerattachment and to the compatibility between PEG and albumin, thus makingPEG-Alb look like native albumin (47a).

Unlike synthetic colloids, PEG-Alb retains important physiologicfunctions of albumin, including roles as an osmolyte, as an antioxidant(38a) and as a transporter of less soluble metabolites such as heme andbilirubin, features that are not associated with other crystalloids andcolloids. Studies involving a variety of PEG-modified proteinsdemonstrate no significant toxicity (48a). The first generation(PEG-Alb₁) developed was more effective than albumin or saline in cecalligation and puncture (CLP) and lipopolysaccharide (LPS) models ofsevere sepsis. Animals treated with PEG-Alb₁ exhibited moreintravascular retention of the colloid, better hemodynamics, lesscapillary leak, and less lung injury. The increased hydrodynamic radiusof PEG-Alb₁ reduced its extravasation and reduced end organ injury whilemaintaining blood pressure and organ perfusion. In addition, thebiophysical characteristics of PEG-Alb₁ such as high colloid osmoticpressure (COP) and high viscosity allows for lowering the “transfusiontrigger” point, which is defined as the hemoglobin (Hb) level belowwhich peripheral tissues suffer from inadequate perfusion (49a).

The extravasation of albumin during capillary leak(ischemia/reperfusion) in hemorrhagic shock is critical. Specifically,this loss of albumin from the intravascular space is injurious in twomajor ways. First, the oncotic force of the albumin is lost, allowingfor tissue edema contributing to the development of multi-organdysfunction. Second, the antioxidant effect offered by albumin issignificantly diminished, allowing for oxidant stress to continue tocause vascular injury and perpetuate the capillary leak andextravasation of more albumin. While not wishing to be held to theory,the inventors herein believe that administration of a larger (largerhydrodynamic radius) and functionally preserved (Cys-34 preserved as athiol for its antioxidant function) albumin (PEG-Alb_(Cys-34)) improvesoutcomes in experimental hemorrhagic shock.

In one aspect, the present invention relates to PEG-Alb_(Cys-34) as aresuscitation fluid for treatment of hemorrhagic shock.PEG-Alb_(Cys-34), with a large effective hydrodynamic radius, will notleak from the intravascular space as is seen with unmodified albumin incapillary leak accompanying ischemia-reperfusion injury (I/R) and shockstates. Retention of PEG-Alb_(Cys-34) in blood vessels makes ofPEG-Alb_(Cys-34) more effective than unmodified albumin and otherresuscitation agents, while retaining the ligand binding, antioxidant,anti-inflammatory and anti-apoptotic functions of albumin.

In another aspect, the present invention is especially useful inmilitary applications. First, PEG-Alb maintains vascular volume asevidenced by better blood pressure recovery after resuscitation in LPSand CLP models of shock. The data also indicate that PEG-Alb is alsoeffective in hemorrhagic shock. Second, because of its biophysicalcharacteristics (high COP, high viscosity), PEG-Alb can lower thetransfusion trigger to levels below 7 g/dl. This means that oxygendelivery to peripheral tissues is maintained at lower hemoglobin levelfor a longer time prior to blood transfusion. Third, PEG-Alb can belyophilized and rehydrated so that it can be stored and reconstitutedunder adverse conditions.

Physiological Studies

PEG-Alb₁ was examined in three different models of shock, two that mimicseptic shock (CLP and LPS) and one that mimics hemorrhagic shock (HS).These studies show that PEG-Alb_(Cys-34) is a more effectiveresuscitation agent than PEG-Alb₁, starches and HTS.

Animal Models

CLP model—Albumin modified at multiple sites with methoxy polyethyleneglycol was evaluated. This material is more effective than albumin orsaline in maintaining MAP. PEG-Alb₁ was also more effective inmaintaining serum colloid osmotic pressure. A mixture of mPEG5000 andalbumin was no more effective than albumin alone or saline inmaintaining blood pressure, indicating that the effectiveness of PEG-Albrequires that the PEG be covalently attached to the protein. As shown inFIG. 15, blood levels of free PEG5000 drop rapidly after intravenousadministration as it is passed in urine, in keeping with studies (50a)indicating that free PEG is readily excreted. When PEG-Alb₁ andunmodified albumin labeled with fluorescein and Texas Red respectively,were administered to CLP rats, the fluorescein label was retained withinthe lung vasculature while Texas Red was detected in the lungextravascular space as seen by fluorescence microscopy in FIGS. 16A andB. Both fluorescein labeled PEG-Alb₁ and Texas Red labeled albumin wereseen only in the intravascular space of control animals. These resultsare consistent with the retention of PEG-Alb₁ in blood vessels duringcapillary leak due to its larger size.

Endotoxin model—PEG-Alb₁ in a rat LPS model of shock was also examined.Consistent with the result in the CLP model, PEG-Alb₁ was more effectiveat maintaining MAP compared to unmodified albumin or saline. Inaddition, administration of PEG-Alb₁ before LPS treatment significantlyreduced lung injury compared to saline or albumin treatment.Inflammatory histopathologic changes consistent with severe acute lunginjury, including hyalinization and interstitial lymphocyte infiltrates,were detected in most rats treated with saline or albumin while thesechanges were less evident in rats pretreated with PEG-Alb₁;representative H&E sections are shown in FIG. 17 to illustrate thescoring of lung injury. Acute lung injury scores were significantlylower for PEG-Alb₁ (1.1±1, p<0.01) compared to saline (1.8±0.4) andalbumin (2±0.63) treated animals. No significant histopathologic changeswere detected in the kidney. This result indicates that PEG-Alb₁maintains the integrity of the endothelium, in addition to its effectsin maintaining blood pressure; however this effect was not seen whentreatment of PEG-Alb₁ was initiated after LPS induction of shock. Theabsence of protective lung injury effect in the post-LPS modelhighlighted the importance of protecting the thiol group (Cys-34) withPEG-ylation.

Hemorrhagic shock model (HS)—The effectiveness of PEG-Alb₁ to unmodifiedalbumin and saline in a rat volume controlled HS model was compared.Blood (2.6 ml/100 g b.w.) was drawn over 10 minutes simulatinghemorrhage; after 90 minutes, resuscitation was initiated with saline,albumin or PEG-Alb₁. As shown in FIG. 18, PEG-Alb₁ was more effective inmaintaining blood pressure than albumin or saline. Groups showed similardeclines in MAP 15-25 minutes after hemorrhage and similar recovery at90 minutes. PEG-Alb treated animals exhibited significant increase inMAP at 40, 50 and 60 minutes from starting the treatment compared tosaline or albumin treated animals. PEG-Alb₁ had a slower decline in MAPand greater plateau MAP response after treatment (p<0.01). Htc droppedafter hemorrhage (table I) with a further decline followingresuscitation, which was greatest for PEG-Alb₁ resuscitation, consistentwith greater intravascular retention of PEG-Alb compared to albumin(P<0.02). COP of saline and albumin treated groups was significantlylower than PEG-Alb₁ group (FIG. 18 a Table I). These results areconsistent with the septic shock model, showing that the efficacy ofPEG-Alb₁ is not dependent on the model of shock.

EXAMPLE IV-1 Physiological Comparison of PEG-Alb_(Cys-34) to OtherResuscitation Agents

Experimental Model of Hemorrhagic Shock

PEG-Albs, including albumin in which cys 34 is retained as a thiol(PEG-Alb_(Cys-34)) are compared with other resuscitation agents in awell characterized rat HS model (51a-53a). a number of physiologicalparameters are examined that reflect the severity of different aspectsof shock, including those related to lung injury, tissue perfusion (baseexcess, lactic acid), arterial blood gases (ABG), mean arterial pressure(MAP), heart rate (HR) and indices kidney function (creatinine). Thisinformation is used to compare PEG-Albs to established agents such asunmodified albumin, starch and hypertonic saline. PEG-Albs is alsocompared with different extents of PEG modification, with different sizePEG, and with different protein-PEG linkages in order to optimize theperformance of the PEG-Albs. The experimental model mimics circumstancesthat occur in real life. Phase I (pre-hospital) corresponds to theinitial trauma and the time required to transport an individual tolocation where resuscitation can be given in the field. This couldcorrespond in practice to resuscitation given by an EMT arriving inambulance or to resuscitation provided by a medic in a combat zone.Phase II (hospital) corresponds to treatment that would be providedafter an individual has been transported to a hospital and where bloodtransfusion can be administered. Phase III (observation phase) is meantto correspond to the time after treatment in a hospital or arehabilitation center. The following protocol is used:

Phase I (Pre-hospital)—HS is initiated by volume-controlled hemorrhage(2.6 ml/100 g b.w. over 20 min (H20). Shed blood is retained forreinfusion. At 20 min, MAP is controlled between 40-45 mm/Hg by fluidresuscitation with LR or by blood withdrawal until 80 minutes. At 80minutes rats are randomized to treatment groups. Treatment is infusedover 30 minutes until 110 minutes to simulate resuscitation that wouldbe given in the field.

Phase II (Hospital phase)—At 110 minutes, the shed blood is infused over10 minutes to simulate transfusion. In previous studies, using thismodel, some rats died early in phase II with severe hypoglycemia andmetabolic acidosis; bicarbonate solution and glucose will be infused torestore MAP to >70-80 mm/Hg and glucose >150 mg/dl until H 270 minutes(53a).

Phase III (Observation phase)—Catheters are removed; anesthesia isdiscontinued, rats are returned to their cages with access to food andwater, and observed until 72 hours. Survivors are evaluated every 24hours using the rat overall performance score (54, 55) 1=normal,2=moderate disability, 3=severe disability, 4=coma 5=death). Necropsiesare performed on rats that die before 72 hours. Survivors areeuthanized. In phases 1, and II rats are anesthetized with pentobarbital(50 mg/Kg i.p) with extra doses (12.5 mg/Kg) given as needed foragitation. Incisions are treated with Bupovacaine (Marcaine 0.025%). Theprotocol is shown schematically in FIG. 19. Arterial blood (0.3 cc) isdrawn to monitor PO₂, PCO₂, pH, O₂ saturation, lactate, glucose,hematocrit, base excess, and electrolytes, (Stat Profile Ultra Gas andElectrolyte Analyzer, NOVA Biomedical, Waltham, Mass.). Blood is takenat 0, 20, 45, 90, 150, and 270 minutes and replaced with RL. Blood atbaseline and following euthanasia is analyzed for creatinine, PT, PTT(some synthetic colloids are associated with coagulopathy), albuminlevels, viscosity (Cone-Plate Viscometer) and colloid osmotic pressure(Model 4420 colloid osmometer Wescor Inc., Logan, Utah). Blood samplingis minimized to prevent cardiac arrest resulting from profoundhypotension.

Results: Data indicates that the first generation PEG-Alb (PEG-Alb₁) ismore effective than saline or albumin

The comparison is extended to other standard resuscitation agents.PEG-Alb with protected thiol (PEG-Alb_(Cys-34)) is tested. Albumin at25% has proven to be effective in hemorrhagic shock while 5% albumin hasnot (40a, 56a); it is important to point out that the volume ofresuscitation agent per se is significant (the same amount of albumin isgiven but in a more concentrated form). The reason the concentrated formis superior may be explained by the fact that threshold concentration ofalbumin being required to exert the antioxidant effect. Alternativelyhyperosmolarity associated with the use of 25% albumin might contributeto the anti-inflammatory effect (40a). Albumin and PEG-Alb at 5% and25%, are compared based on albumin content. Hetastrarch 6% (Hexstend®)is also used in resuscitation and is compared to PEG-Albs Hypertonicsaline (7.5%) is a third resuscitation agent that is compared toPEG-Albs.

Capillary Leak Studies

While not wishing to be held to theory, the inventors here believe thatPEG-Albs will be retained within blood vessels during capillary leakconditions and thus maintain the colloid-osmotic pressure of blood. Wehave shown that PEG-Alb₁, which is 16 times larger than albumin,extravasates less in capillary leak conditions associated with CLP andLPS models (42a). We determined this is also the case in hemorrhagicshock model. Using a method we developed, fluorescently labeled albuminand PEG-Alb (Texas Red, TR) and PEG-Alb (fluorescein, F) are injectedinto rats and a small volume of blood is taken through the tail vein foranalysis at different times after injection. Preparation of the labeledalbumins is described in the section of this proposal dealing with thebiophysical characterization of the PEG-Alb. If albumin is lost to theextravascular space and PEG-Alb to be retained, the ratio of fluoresceinto Texas Red (F/TR) will increase with time, consistent with loss ofalbumin and preferential retention of PEG-Alb. The excitation andemission spectra of Texas Red and fluorescein are sufficiently differentthat mixtures of the two dyes can be examined quantitatively in serumsamples. The distribution of albumin and PEG-Alb is also examinedqualitatively in frozen tissue sections of lung by fluorescencemicroscopy to determine if the PEG-Alb is retained within blood vessels,as observed in the models of septic shock (FIGS. 16A and B).

The labels (fluorescein albumin and Texas Red PEG-Alb) are switched toverify that the fluorophor does not alter the distribution of theprotein. The bronchoalveolar lavage (BAL) is examined for thefluorescent albumin and PEG-Alb; if TR albumin leaks preferentially, onewould expect the ratio of F/TR in BAL to decrease. This method is usedto compare PEG-modified albumins that we have produced to determine ifone is more effectively retained than others.

In an other aspect, an alternate approach is useful to study lungpermeability and employs Evans Blue Dye (EBD), which is not permeable toblood vessels (57a). Rats are injected with 1% EBD solution through aninternal jugular vein catheter twenty minutes before euthanasia. Afterallowing for complete circulation of the dye (5 minutes), blood is drawnand EBD concentration is determined in plasma. Rats are euthanized andthe lungs, livers are harvested. BAL is performed on the excised lungsby instilling five milliliters of normal saline three times. The leftlung lobe is tied off to prevent influx of saline to preserve this lungfor the wet-to-dry weights. The lung that was not infused with saline istaken for weighing and is put in a vacuum oven for drying andsubsequently measure the wet/dry as a surrogate for extravascular fluidleak. The combined BAL fluid is centrifuged to remove cells, and thesupernatant is assayed for EBD. The concentration of EBD in the BALfluid is expressed as the percentage of that present in the plasma. Thatis, BAL/Plasma EBD is compared between the treatment groups along withthe wet/dry of the lung tissue.

Hemodynamics

A feature of PEG-Alb₁ compared to saline and albumin in the septic shockmodels is its capacity to maintain blood pressure and preventhemoconcentration. An important issue in the hemorrhagic shock model ishow well PEG-Alb_(Cys-34) performs compared to standard resuscitationagents. Rats are anesthetized with sodium pentobarbital followed bymaintenance sedation as needed. An arterial catheter (Intramedic PE-50,Clay Adams) is inserted into the right carotid artery, connected to apressure transducer, amplified and continuously monitored (sampling rate100 Hz; MP 100, BioPac Systems Inc., Santa Barbara, Calif.) andcollected on a computer. An intravenous line (G24 Protective*Plus,Johnson and Johnson/Ethicon, Arlington, Tex.) is inserted in the leftjugular vein for infusion of fluids. MAP and HR in animals given variousfluid resuscitation agents is monitored. In the pre-hospital phase, allthe rats are subjected to similar levels of ischemia for a minimum of 60minutes, after which they are randomized to treatment groups. Thecrystalloid group receives three times the volume of the colloid groups,and eight times the volume of HTS group. PEG-Albs shows superiorperformance in MAP starting in the initial phase (pre-hospital) based onthe fact that CL can occur as early as 20 minutes after hemorrhagicshock (58a). In the Hospital phase, PEG-Alb_(Cys-34) group performanceis superior to the other treatment groups for the following reasons: 1)Following treatment (reperfusion), capillary leak becomes even moresevere and here PEG-Alb is more retained in the vascular space; 2) Incontrast to crystalloids and synthetic colloids. PEG-Alb_(Cys-34)improves the sensitivity of the blood vessels to the endogenous pressorsby decreasing the oxidation products (10a).

Perfusion Studies

Hypoperfusion of vital organs during hemorrhagic shock is a primarycause of organ dysfunction. A number of physiological parametersindicative of reduced blood flow are examined in order to comparePEG-Alb to other resuscitative agents.

a. Lactic Acid—Lactic acid levels correlate with subsequent organfailure in hemorrhagic shock (59a). Increased levels of epinephrine(secondary to shock) decreases ATP by stimulating the activity of Na⁺-K⁺ATPase (60a), as a result lactate production increases due tomitochondrial dysfunction and anaerobic glycolysis. Improving theperfusion in PEG-Alb treated groups is expected secondary to thefollowing factors: 1) better maintenance of systemic blood pressure and2) better perfusion at the microcirculation level enhanced by thebiophysical characteristics of PEG-Alb (increased COP and viscosity).This increases the shear stress at the capillary level stimulating theincrease in nitric oxide, which results in vasodilation and improvedperfusion (49a).

b. Base Excess (BE) Fencl-Stewart (61a, 62a) method. Base deficit isdefined as the amount of base required to titrate one liter of wholeblood to a normal pH at normal physiologic values of PaO₂, PaCO₂, andtemperature (63a). BE is obtained by multiplying the deviation instandard bicarbonate from a mean of 22.9 by a factor of 1.2 (64a).Calculation of BE assumes normal water content, electrolytes, andalbumin. This is relevant since significant change in plasma albuminconcentration is expected. A decrease in albumin by 1 g/dl decreases theBE by 3.7 mEq/L (61a). BE corrected for changes in sodium, chloride, andalbumin in a cohort of pediatric ICU patients showed a bettercorrelation with mortality than calculated BE, anion gap and lactate(62a). Any value ≧−5 mEq/L is significant. Base excess corrected forunmeasured anions (Beua) is defined by:Beua=BE−(Befw+Becl+Bealb)

-   -   The terms in this expression are:        -   BEua—BE corrected for unmeasured anions.        -   BEfw—Base excess caused by free water effect=0.3*Na−140        -   BEcl—Base excess caused by changes in chloride=102−Clcor,            where Clcor=CL*140/N        -   BEalb—Base excess caused by changes in            albumin=3.4*(4.5−albumin).

c. Viscosity—During treatment of hemorrhagic shock, resuscitation usinglarge volumes of crystalloids and colloids lowers hematocrit and bloodviscosity. Historically, the use of colloids and crystalloids in thecorrection of blood loss was considered safe up to a level called thetransfusion trigger (50% Hb lost or Hb of 7 g/dl) (65a). When thehematocrit drops below 50% of baseline, the shear stress at thecapillary level will be lowered, resulting in vasoconstriction anddecreased oxygen delivery to the tissues. Studies bt Tsai's group andothers (49a, 65a, 66a) indicate that increased viscosity helps maintainoxygen delivery to tissues prior to blood transfusion or other agentsfor delivery of oxygen to tissues. PEG-Alb should increase viscosity asother polymerized proteins do (67a). When PEG-Alb was given at 3 g/dl toCLP rats, serum viscosity (measured with a Cone-Plate Viscometer) was at3 cP, a level considered necessary to maintain the oxygen delivery atthat degree of hemodilution (66a). As shown in FIG. 20, viscosity islinearly dependent on the concentration of PEG-Alb while colloid osmoticpressure has nonlinear concentration dependence.

EXAMPLE IV-2 Analysis of the Effectiveness of PEG-Alb_(Cys-34) inSuppressing Oxidative Stress and Systemic Inflammatory Responses

In vivo studies show that “maintaining PEG-Alb_(Cys-34) in the vascularspace following ischemia/reperfusion injury where the oxidative stressis intense and the native albumin is leaking” results in augmenting theantioxidant capacity in the vascular space, decreasing apoptosis andcontrolling of inflammation.

Inflammation Studies

NF-κB is activated following hemorrhagic shock, leading tooverexpression and production of cytokines such as TNF-α (68a). Theactivation of NF-κB during ischemia (69a) or during resuscitation (70a)is considered an important step in initiating and maintaining theexaggerated inflammatory response. Importantly, the volume in whichalbumin is administered appears to play a significant role ininflammation. 25% Albumin, but not 5% or R/L, decreased neutrophilsequestration in the lung and prevented lung injury followingshock/resuscitation (40a). This is the basis for testing albuminpreparations using the two concentrations.

a. Histology—Acute lung injury (ALI) and diffuse alveolar damage (DAD)are frequent complications after hemorrhagic shock and are frequentlyassociated with severe inflammatory response (71a). Formalin fixed lungtissues are subjected to standard hematoxylin and eosin stainprocessing. Coded specimens are examined by light microscopy by ablinded pathologist, who score the acute inflammatory lung injury usinga five-point system: 0, no significant histopathologic changes; 1,minimal interstitial inflammatory infiltrates; 2, mild interstitialinflammatory infiltrates with mild hyalinization; 3, moderateinterstitial inflammatory infiltrates with moderate hyalinization; 4,severe interstitial inflammatory infiltrates with severe hyalinization.To ensure consistency, samples are examined twice, and the scores areaveraged.

b. Myeloperoxidase in lungs—The interaction between neutrophils anddifferent cells, especially endothelial cells, plays a critical role inorgan injury after resuscitation. Myeloperoxidase activity in lungextracts is measured as a measure of neutrophil sequestration, which isrelated to the severity of inflammation (72a).

c. Cytokines—Following reperfusion, the local inflammatory reactioninvolves cytokines such as TNF-α (73a, 74a) in addition to neutrophilrecruitment. In the same HS rat model, plasma levels of TNF-α and TNF-αmRNA in liver increased significantly 20 minutes after the end ofbleeding (4a). It has been shown that high concentrations of albumindecreased the production of proinflammatory cytokines such as TNF-α andIL-6 (39a, 75a). TNF-α and IL-6 is measured in lung and liver tissueduring phases II and III. Standard cytokine assays is performed also insera at baseline and following the end of phases I, II and III accordingto the manufacturer's protocol (Pharmingen, San Diego, Calif.).

d. NF-κB activation−NF-κB activation occurring in the ischemic phase orfollowing resuscitation is tied to the dysfunctional inflammatoryresponse in hemorrhagic shock and resuscitation. Liver NF-κB bindingactivity measured by electrophoretic mobility shift assays increased inthe nuclear extracts 10 minutes after the end of bleeding. Western blotstudies showed that the levels of inhibitory protein IκBa in cytoplasmicextracts decreased at 5 minutes after the end of bleeding (4a).Proinflammatory cytokines contain NF-κB binding sites (76a); increasedNF-κB binding to their sites results in increased cytokine expressionleading to increased inflammation and tissue injury. This means thatdown regulation of NF-κB is expected to reduce inflammation. It had beenshown in cell culture systems that albumin increased intracellularglutathione sufficiently to prevent TNFα-induced NF-κB translocation(77a). NF-κB is measured in lung and liver following phases II and III.Reduction in NF-κB is used as an indicator of a positive resuscitationeffect. Electrophoretic mobility shift assays are used to measure NF-κBand Western blot analysis to measure IκBα (4).

EXAMPLE IV-3 Apoptosis and Oxidation

Ischemia-reperfusion results in disrupting endothelial integrity (78a,79a). When pulmonary artery endothelial cells (EC) were exposed toischemic human plasma, ten minutes later they became rounded, formedgaps and then blebbed (80a, 81a). The same morphologic changes occurredin microdermal EC culture after exposure to sera from capillary leaksyndrome patients (12a). Apoptosis of EC was evidenced by morphologiccriteria, plasma phosphatidylserine exposure (Annexin staining), and DNAfragmentation. Increased Bax/Bcl2 in endothelial cells was detected byimmunohistochemistry. The mechanism of these effects was explored bymeasuring intracellular reactive oxygen species (ROS) and the resultssuggested that oxidative injury played a role in the mechanism of ECapoptosis (12a). Oxidative stress is a well known inducer of apoptosis(11a). In addition increased apoptosis occurs after trauma andhemorrhage (15a, 78a, 79a, 82a). Inhibition of apoptosis by caspaseinhibitors attenuated I/R induced inflammation (36a, 83a, 84a). Intissues exposed to ischemia-reperfusion, antioxidants minimized thedamage from this injury. Albumin is the major extracellular antioxidantin plasma. It exerts this function through the enzyme gammaglutamylcysteine dipeptide, where albumin plays a significant role inglutathione synthesis (38a). Glutathione is the main low molecularweight soluble thiol present in mammalian cells, (85a) its depletionplays a role in the induction of apoptosis (86, 87). In another studylooking at how albumin exerts its antioxidant activity (40),modification of the single free thiol (cys 34) was accompanied by a 45%decrease in antioxidant activity (88a). Albumin is protected againstoxidation by its capacity to increase glutathione (GSH). Conversely,reduction in GSH led to a) activation of caspase 3 and poly ADP ribosepolymerase (PARP) fragmentation (89a), and b) the decrease in Bcl-2/Baxratio. The latter ratio is a strong indicator of cell survival,particularly in defense against oxidative injury (90a, 91a). As aresult, albumin, through its function as antioxidant, contributessignificantly to, the protective effect against apoptosis. In referenceto the endothelium, albumin reduced microvascular permeability (33a,92a, 93a) and played an essential role in preventing apoptosis ofendothelial cells (36a, 84a).

EXAMPLE IV-4 The Effect of PEG-Alb_(Cys-34) on Cellular Injury FollowingI/R in Lung and Liver Tissues

a. TUNEL assay—This method uses terminal deoxynucleotidyl transferase tolabel DNA strand breaks with fluorescein-conjugated nucleotides (94a).Apoptosis detection kit (Boehringer, Indianapolis, Ind.) will be used.Tissue samples are examined by a blinded pathologist. B. Western blotanalysis of apoptosis markers—Tissue samples are quick-frozen and storedat −80° C. until extracted for Western blot analysis. Apoptosis isdetected by examining a number of proteins whose presence ormodification is associated with apoptosis. Rhe expression ofproapoptotic protein bax and the antiapoptotic protein bcl-2 usingwestern blot analysis are examined. Tissue extracts for cleavageproducts of poly ADP-ribose polymerase (PARP) are analyzed. PARP is asubstrate for caspases 3 and 7 and an accepted marker for apoptosis.Full length PARP (115 Kda) is cleaved into fragments of 85 to 90 Kda and23 to 24 Kda resulting in inactivation of its enzymatic activity (11,95).

b. Immunohistochemical staining for bax and caspase-3—Tissues areembedded in paraffin and cut into 5-micron thick sections forimmunostaining. Sections are prepared from HS animals and controlanimals. A polyclonal rabbit antibody specific for active caspase-3 isused. Distribution of caspase 3 in thin sections of tissue aredetermined by immunostaining using a fluorescent secondary antibody. Forco-localizing the endothelium, CD34 and factor VIII stains are used.Negative control sections receive identical treatment except for theprimary antibody. Immunostained slides from control and treated animalsare coded and read at 40× magnification by blinded readers. Two separatereadings are obtained for each slide and expressed as the percentage ofpositive cells/mm² tissue.

c. Measurement of glutathione—Oxidative stress accompanying HS isreflected in the ratio of reduced to oxidized glutathione GSH/GSSG.Accordingly, reduced and oxidized glutathione in the lung according aremeasured according to the procedure described by Hissin and Hilf (96).Frozen tissues are extracted with TCA, neutralized and GSH and GSSGcontent in the extract are determined by reaction with o-phtaldialdehyde(OPT) and the resulting fluorescence is monitored using authentic GSHand GSSG as standards. The GSH/GSSG increases following treatment withPEG-Alb_(Cys-34) compared to the other groups including PEG-Alb₁. Thiscorrelates with less apoptotic activity as evidenced by less PARP anddecreased bax/bcl-2.

d. Measurement of malondialdehyde—Malondialdehyde (MDA) in tissueextracts is also used as a marker for oxidative stress associated withHS. Malondialdehyde (MDA) (97a) and Total Antioxidant Capacity (TAOC)(98a, 99a) in the lung and liver harvested after sacrifice isdetermined. MDA is assayed employing an HPLC method (94a). MDA an earlymarker of lipid peroxidation and, along with the TAOC, increases whilethe GSH/GSSG ratio is expected to decrease.

EXAMPLE IV-5 Production and Biophysical Characterization of PEG-Albs

In parallel with the examples of the in vivo efficacy of thePEG-albumin, physical studies on the modified albumins are performed toidentify properties that correlate with its in vivo effectiveness intreating shock.

Methods of synthesis, product size distribution, effects of modificationon protein secondary structure and conformation, the effect of PEGmodification on oncotic properties of albumin and effects on the bindingof physiologically relevant ligands are evaluated. The example IV-5adescribes preliminary studies on the preparation and properties ofPEG-Albs and the example IV-5b describes the proposed studies.

EXAMPLE IV-5a Preliminary Biophysical Studies of PEG-Albs

1. Preparation and Size Analysis of PEG-Albs

Because the mode and extent of modification and the size of mPEG(methoxypolyethylene glycol) attached to albumin may alter itsbiophysical properties and in vivo properties, we have examineddifferent methods for linking PEG to albumin and have characterized themodified proteins with respect to size, stability and osmoticproperties. We examined N-hydroxysuccinimide esters (mPEG5000), cyanuricchloride (mPEG5000), and thiol selective maleimide derivatives(mPEG20000 and mPEG40000).

The cyanuric chloride (mPEG5000) derivatives have been tested inanimals. These modes of modification are simple, rapid and most of thealbumin is modified. Excess reagent and any unmodified albumin areremoved by gel filtration or ion exchange chromatography. NHS esters andcyanuric chlorides (both selective for lysyl ε-amino groups) andmaleimides (selective for cysteinyl thiols) are commercially availableand react readily under mild conditions. FIG. 21 shows the results ofanalysis of albumin modified with cyanuric chloride mPEG5000. Asexpected for a reagent that modifies multiple residues, CNCI-mPEG5000modified albumin is heterogeneous when examined by SDS gelelectrophoresis (M_(r,app)>250,000) or by gel filtration on Superose 6(M_(r,app)>450,000). The molecular weights of species seen on SDS gelsare uncertain due to the extended nature of PEG and the fact that it maynot bind the same mass of SDS as proteins used as standards. Albumin canbe modified more extensively with this reagent by increasing the ratioof reagent to protein during modification. Product heterogeneity can bereduced by size selection by gel filtration. FIG. 22 shows the resultsof Superose 6 analytical gel filtration of material that wasfractionated on a preparative Sephacryl S300 column (designated I, IIand III) along with unmodified albumin and unfractionated material(designated U).

Because human albumin's single thiol (100-102) has an unusually low pKa(approximately 5.5), it is modifiable with thiol selective reagentswithout perturbing the disulfide structure of the protein. Acccording toone aspect of the present invention we have attached mPEGs of differentsizes (a 20,000 Mr derivative and a branched 40,000 Mr derivative).Albumin is incubated with dithiothreitol and low molecular weightproducts linked to the albumin through cys 34 are removed by SephadexG50 chromatography followed by modification with maleimide mPEG40000.FIG. 23 shows the results of purification of the mPEG40000 modifiedalbumin on Q-Sepharose. Unlike the CNCI-mPEG5000 modified albumin, thismaterial is homogenous, consistent with modification of a singlecysteinyl residue. We have prepared an mPEG20000 albumin using the sameapproach and it also behaves as a homogenous protein. Consistent withbehavior on SDS gel electrophoresis, mPEG20000 and mPEG40000 albuminselute as single symmetrical peaks when examined by gel filtration onSuperose 6 as shown in FIG. 24. These modified proteins elute at sizessignificantly greater than would be expected given the predictedmolecular weights (87,000 for the mPEG20000 albumin and 107,000 formPEG40000 albumin) for the singly modified species. This behavior isconsistent with the extended structure of these PEGs. SELDI massspectrometry of the PEG40000 albumin gave a single broad peak centeredat 108,000 Mr indicating that it is singly modified. The behavior ofthese modified albumins on gel filtration shows that they have extendedstructures due to the extended structure of the PEG.

2. Thermodynamic Stability and Conformation of the PEG-Albs

An issue in the analysis of these PEG-Albs is whether the modificationalters native structure and potentially the ligand binding propertiesand stability of the albumin. We examined the stability of PEG-Albs byanalyzing urea induced unfolding; this is a standard method for studyingthe thermodynamic stability of proteins which gives the free energy ofunfolding and can reveal whether the protein assumes unfoldedintermediates (103a-105a). The protein is incubated with increasingconcentrations of denaturant and a spectroscopic signal characteristicof the native and unfolded states is examined. We used the shift in thefluorescence emission wavelength (intensity averaged emission wavelength<λ>) of the tryptophan (trp 214) as a signal since there is asignificant red shift when the protein unfolds (106a). Examples ofresults of such studies comparing unmodified albumin (panel A), albuminmodified with mPEG20000 (panel B) and albumin modified with mPEG40000(panel C) are shown in FIG. 25. Studies by others indicate thatunmodified human albumin shows a complex unfolding pathway with at leastone intermediate species (106a, 107a), which our results confirm. Theunfolding of the mPEG20000 and mPEG40000 modified albumin are remarkablein their similarity to unmodified albumin (FIG. 15, panel A), with thePEG-modified albumins being only slightly destabilized relative tounmodified albumin. The mPEG20000 modified albumin shows a slight blueshift at intermediate concentrations of urea suggesting the environmentof the tryptophan in a partially unfolded intermediate species may bealtered. With both mPEG20000 and mPEG40000 modified albumin, themidpoint of the unfolding occurs at a similar concentration to that forunmodified albumin (7M). We have performed similar unfolding studies ondifferent size-fractionated, multiply modified mPEG5000 albumins and theresults are similar to those obtained with the singly modified albumins.Overall PEG modification is not significantly destabilizing.

We also compared one of the PEG-Albs (PEG40-Alb) to unmodified albuminby differential scanning calorimetry (DSC). This approach givesinformation on the thermodynamic stability and can be employed to studythe effects of ligands on conformation and stability. FIG. 26 shows theresults of DSC experiments with PEG-Alb40 (PEG40) and unmodified albumin(Alb). The DSC scans are complex in part due to bound fatty acids thattend to stabilize the protein to thermally induced unfolding. Theimportant feature is that the PEG40-Alb shows the same features asunmodified albumin. The transition temperature for the first transitionseen with PEG40-Alb reflects removal of more of the fatty acids from thePEG40-Alb compared to albumin (108a-111a). The results indicate that thePEG40 modified protein retains the native structure of unmodifiedalbumin.

To extend the studies of stability, we examined the fluorescence of thesingle typtophanyl residue to quenching by different agents. Thetryptophan fluorescence can be used as an indicator of native structure,since subtle changes in protein conformation can alter the emissionintensity and the shape of the emission spectrum (112a, 113a).Modification of albumin with mPEG5000 contributes to absorbance in theultraviolet (between 240 nm and 280 nm), while the absorption spectraand the fluorescence emission spectra of the PEG20000 and PEG40000modified albumins were virtually indistinguishable from unmodifiedalbumin. Fluorescence emission spectra for the mPEG 5000, PEG20000 andPEG40000 derivatives were similar to unmodified albumin indicating thatthe environment of the single tryptophanyl residue has not been alteredsignificantly.

We examined the accessibility of tryptophan to the solvent bydetermining how readily its fluorescence could be quenched by iodide oracrylamide. FIG. 27A shows acrylamide quenching studies on mPEG5000albumin that had been size fractionated to select for PEG-Albs withdifferent extents of modification; the fraction designations correspondto the samples analyzed by gel filtration in FIG. 22. The least modifiedfraction (designated III) was similar to unmodified albumin. Fractions Iand II showed greater susceptibility to quenching by acrylamide, whichis manifested primarily in a static quenching component reflected in theupward curvature of the plot. This result suggests that the acrylamide,which is somewhat hydrophobic, binds to the surface of the PEG-Albs. Wealso examined quenching by KI, which is a charged, polar quenchingagent, as shown in FIG. 27B. While the tryptophan of albumin is buriedand not particularly susceptible to quenching by iodide, increasinglevels of modification with PEG slightly reduced its susceptibility toquenching as seen with fractions I and II, suggesting PEG modificationfurther shields the tryptophan from the solvent and polar solutes. Incontrast, the PEG20000-Alb and PEG40000-Alb exhibited only small changesin acrylamide quenching (shown in FIG. 27C) and no change in iodidequenching (not shown). These examples show that modification of albuminat multiple sites with PEG5000 further shields the interior of theprotein from the solvent and polar solutes, while modification withPEG20000 or PEG40000 do not.

3. Osmotic Properties of PEG20-Alb and PEG40-Alb

Because the osmotic properties of the modified albumins are essentialfor function in vivo, we examined the dependence of colloid osmoticpressure on the concentration (114a, 115a) of mPEG20000, mPEG40000,multiply modified mPEG5000 albumins and unmodified albumin as shown inFIG. 28. On a molar basis, mPEG20000-Alb, mPEG40000-Alb and mPEG5000-Albexerted greater osmotic pressure at higher concentrations thanunmodified albumin while at low concentrations the osmotic pressure wassimilar to that of albumin; the serum concentration of albumin isapproximately 0.6 mM. The nonideal behavior seen at high concentrationswith the mPEG-Albs reflects the larger excluded volume of these speciesand the extent of hydration. We have also examined size fractionatedmPEG5000 modified albumin and the more heavily modified fractions exertgreater osmotic pressure than the less heavily modified. These studiesare consistent with the molecules having large excluded volumes, aproperty that aids in their retention within blood vessels and maintainan oncotic gradient that will reduce extravasation of fluid into thetissue interstitial space.

4. Albumins with Fluorescent Labels

We have prepared unmodified albumin and mPEG-Albs with fluorescein orTexas Red linked through cys34. These fluorescent albumin derivativesare used to examine how effectively the albumin is retained in thecirculation in animals with capillary leak; disposition of thesealbumins can be monitored fluorometrically in body fluids or byfluorescence microscopy of tissue sections. The two fluorophors havewell separated excitation and emission spectra, so samples containing amixture of two albumins (e.g., unmodified albumin with Texas Red andPEG-albumin with fluorescein) can be examined in the same animal. WhenPEG is linked through cys34, we couple amine reactive versions offluorescein or Texas Red through a lysyl ε-amino group. Having albuminwith two different fluorophors allows for the determination of howefficiently the PEG albumin with fluorescein is retained in thecirculation compared to the unmodified albumin with Texas Red. Thesefluorescent albumins are only employed analytically for monitoringretention of unmodified versus PEG-albumin in models of shock or tomonitor the in vivo half-life. We have readily detected the fluorescenceof fluorescein-albumin in dilutions of serum well above the backgroundof other fluorescent material. As necessary, measurements of intensityis corrected for the inner filter effect (112a, 113a) arising from otherchromophors in serum samples; however, our studies with the fluorescentalbumin indicates that any interference is negligible due to the largedilution of the serum that is required (1:1000 to 1:2000).

EXAMPLE IV-5b Biophysical Studies

1. Preparation of PEG-Albumin

We have examined a number of reagents for linking PEG to albumin and themPEG5000-Alb in vivo. Because the size of the PEG attached to albumin,its location and the nature of the covalent linkage results in productswith significantly different stabilities, biological half-lives andligand binding, various modes of attachment and types of mPEG (46a,116a-120a) are examined. For the amine selective reagents that tend tomodify multiple lysyl residues, specific methods are used for preparingmaterial with a more defined size distribution so that the dependence ofefficacy on size is examined. Controlling the size distribution isachieved, in part, by limiting the extent of modification in the initialreaction, by purifying the product by ion exchange or gel filtrationchromatography, and by the selective modification of specific residues,as we have done with the maleimide-PEGs.

Modes of linkage—While the modes of linking the reagent to albumin thatused thus far have produced a product with the desired in vivo effect,it is also within the contemplated scope of the present invention thatother modes of attachment are useful to generate products withdifferences in stability or binding of relevant ligands. PEGs of varioussizes, with different reactive groups (primarily amine and thiolselective) are available (Shearwater Corp., Huntsville Ala.); thissupplier develops reagents specifically for PEGylation of biologicalmaterials. Others have emphasized the importance of attention to thequality of the mPEG reagents and biological optimization (119a). Thepresent invention also contemplates the use of such additional methodsteps of modifying conditions (e.g., pH, ionic strength, temperature)and maintaining of native structure; for example, the disulfide bondingand structure of albumin may be disrupted at high pH due to proteinthiol-disulfide exchange.1. Amine selective reagents—The most abundant class of nucleophilesavailable for modification are surface lysyl residues that are readilymodified to give a highly substituted product. WhilemPEG-succinimidyl-succinate generates a product with an ester linkagethat might be a substrate for serum esterases, other reagents such asmPEG-succinimidyl-propionate (1 in FIG. 29) andmPEG-succinimidyl-butanoate (2 in FIG. 29) are also useful to modify thesame lysyl-residues, but with a more stable linkage and a longerhalf-life in vivo. PEG-aldehyde derivatives (e.g., 3 in FIG. 29) can belinked to lysyl residues through reduction of the resulting Schiff basewith NaCNBH₃ (116a, 119a); this PEG reagent is more selective for lysylresidues and the modified lysyl residue retains a positive charge, whichis a consideration in retaining the anion binding properties of albumin;it also does not introduce a linker. PEG can be coupled directly to aprotein using tresyl chloride activation (121a) and has been employedwith albumin (122a). Linkerless methods (119a) have the advantage thatthey do not introduce a moiety with unknown toxicological properties.While PEG itself does is not immunogenic (123a), the element linking itto protein can be. The extent of modification is evaluated by examiningthe loss of reactive amines using fluorescamine (3a), qualitatively bySDS gel electrophoresis, by examining the size distribution byanalytical gel filtration and by using a calorimetric assay for PEGwhich can be used on PEG modified proteins (124a).2. Thiol selective reagents—Modification through a thiol is a usefulapproach for human serum albumin since it has a single thiol (cys34)(100a, 101a, 125a). Human serum albumin is a mixture of protein withcys34 as a free thiol and a substantial fraction with the thiol modifiedwith glutathione or as a disulfide dimer of two albumins. Under mildconditions, Cys34 disulfides can be reduced such that all of the cys34is available as a free thiol without reduction of the less accessibledisulfides. Cys34 is reactive with thiol selective reagents, includingN-ethylmaleimide and iodoacetamide (100a, 101a, 125a). In oneembodiment, albumin is modified with mPEG-maleimide derivatives (4 inFIG. 16) such that the PEG is linked to a single site on the protein.Modification at a single, unique site is less likely to perturb nativestructure or alter the ligand binding properties of the albumin. Asindicated in the preliminary results section, we have prepared two suchforms of mPEG-Alb. A potential disadvantage of thiol modification isthat it may alter the antioxidant properties of the product.PEG Derivatives of Different Sizes and Geometries

Albumins modified with different size PEGs and PEGs with branchedstructures are examined. Sizes available include 3,400 M_(r), 5,000M_(r), 20,000 M_(r), and 40,000 M_(r). There are branched (3 in FIG. 29)and forked (5 in FIG. 29) versions of PEG with various chemistries forlinkage to proteins (46a, 117a). Larger PEGs allow for modification atfewer sites to achieve the same effective size. The larger sizedistribution is particularly important for linkage through cys34 sincethere is only one PEG incorporated. A consideration relating to reagentsize is that smaller PEG-peptides (e.g. PEG≦1200 (119) are readilycleared through the kidneys, justifying analysis of multiply modifiedalbumin. Increasing PEG chain length prolongs the half-life of thematerial in the circulation (117a, 126a).

Preservation of Cys 34—The activity of albumin in inhibiting apoptosisand other biological properties depend on thiols (presumably cys34).mPEG-Albs that retain cys 34 as a thiol are prepared. Albumin is treatedwith a slight excess of dithiothreitol followed by modification of cys34 with 5,5′-dithiobis-2-nitrobenzoic acid. Low molecular weightproducts are removed by gel filtration and the protein is modified withan amine selective PEG reagent. The free thiol is regenerated bytreating the protein with dithiothreitol to release the thionitrobenzoicacid (monitored spectrally at 412 nm). The mPEG albumin is purified toremove unmodified protein, excess reagent and reaction byproducts. ThemPEG-albumins produced using this approach are modified at multiplesites since the reagents modify lysyl residues. However, it is alsowithin the contemplated scope that the method can include using largerPEG reagents (e.g., PEG20000 and PEG40000) the number of residuesmodified can be minimized by varying reagent concentration and reactionconditions.Size selection and analysis of PEG-albumin—The size distribution of theproduct is important both because the PEG-albumin must be large enoughto be retained within blood vessels during capillary leak and because aproduct that is too extensively modified might have undesirableattributes, such as loss of ligand binding properties or toxicity.Controlling the size distribution is achieved, in part, by limiting theextent of the reaction or, in the case of modification of cys34,modification of a single residue. The modified product is purified bygel filtration or ion exchange chromatography to select for PEG-albuminof a relatively narrow size distribution. The size distribution of thepreparation is determined by gel filtration using proteins of definedmolecular dimensions and M_(r) as standards and by mass spectrometry.One cannot really determine a molecular weight of the modified albuminby gel electrophoresis (127a, 128a) or by gel filtration since the PEGhas an extended structure, and likely does not bind SDS the way proteinsdo. A more appropriate parameter is the equivalent or Stokes radius. Thenumber average molecular weight and the effective molar volume can beobtained from the concentration dependence of colloid osmotic pressure(114a, 115a). Although the exact physical meaning of these measurementsis subject to interpretation, they do provide a basis for comparingdifferent preparations and parameters that can be correlated with invivo effectiveness. These analyses define the extent of modificationthat is required for retention of PEG-albumin within blood vessels inmodels of shock and determine the merits of different extents ofmodification.2. Effect of PEG Modification of Albumin on Protein Structure andStability

The structure and stability of albumin are important for itsphysiological functions. Spectroscopic techniques are used to examineconformation and secondary structure to determine the extent to whichmodification of albumin with PEG alters the protein's structure andstability. Circular dichroic (CD) spectra in the near and farultraviolet are obtained on unmodified albumin and on albumin modifiedwith PEG. Analysis of the near ultraviolet spectra (250 to 320 nm) givesinformation on the extent to which modification has perturbed themicroenvironment of tyrosyl and tryptophanyl residues (129a, 130a). Thefar ultraviolet CD spectra (180 to 250 nm) gives information on theextent to which secondary structure has been perturbed (129a, 130a).Human serum albumin is dominated by α-helix (67%) (100a-102a), and bothspectra reflect this type of secondary structure. Environment oftryptophanyl residues is examined by iodide and acrylamide quenching ofintrinsic tryptophan fluorescence (112a, 113a); examples of suchexperiments are shown in the results section. Tryptophan fluorescence,and its susceptibility to quenchers, is a sensitive probe of proteinconformation. We have examined unmodified albumin and PEG modifiedalbumin by iodide quenching and the single tryptophan is relativelyinaccessible to this quencher with both proteins, consistent with PEGmodification not altering its environment. In addition, the emissionspectra of tryptophan for the two native proteins are essentiallyidentical. These examples identify conditions for modification thatresult in PEG-albumin with minimal alterations in protein conformationand secondary structure.

The effect of PEG modification on the stability of albumin is evaluatedby examining spectroscopic signals (intrinsic tryptophan fluorescenceand CD) characteristic of native structure in the presence of increasingconcentrations of chaotropic solutes (guanidine-HCl or urea). Analysisof such experimental data gives the free energy of unfolding in theabsence of denaturant (ΔG⁰ _(H2O)) (103a, 105a), reflecting thethermodynamic stability of the protein. FIG. 30 shows the results ofunfolding studies of unmodified serum albumin (panel A) and mPEG5000modified albumin (panel B). The unfolding of albumin is clearly acomplex, multi-state process as indicated by the lack of coincidencebetween the CD and tryptophan fluorescence signals, consistent withalbumin being a multidomain protein (100a-102a, 131a, 132a). Unfoldingmonitored by CD is similar for unmodified and multiply mPEG5000 modifiedalbumin (FIG. 30 panel B), showing that modification did not alterstability.

In another aspect, the present invention provides a method to identifyconditions for modification that result in a product with the desiredbiological activity without altering stability. Stability of thePEG-Albs is also be examined by differential scanning calorimetry (DSC)(133a-135a). In this approach one heats a protein solution slowly andmeasures the excess heat capacity associated with unfolding; thisapproach is useful to study the effects of fatty acids and tryptophan onthe stability of albumin (108a-111a). To compare both the ligand-freeproteins and the ligated species, fatty acids, tryptophan and otherhydrophobic ligands are removed by charcoal treatment (108a) and theeffect of adding various ligands including fatty acids, heme,N-acetyltryptophan is examined. This analysis gives information aboutprotein stability (including the enthalpy of unfolding) and the numberof states involved in the unfolding process and can be used to assessthe integrity of the ligand binding sites.

1. Analysis of the oncotic properties of PEG-Albumin—The concentrationdependence of colloid osmotic pressure of PEG-albumins is examined tosee how this property relates to in vivo effectiveness. Unmodifiedalbumin, PEG-Albs and comparable concentrations of the correspondingunconjugated mPEGs are examined. In the simplest case, the osmoticactivity of PEG-albumin is the sum of the osmotic activities of acomparable concentration of unmodified albumin and the free PEG.However, interaction of solvent and solute with proteins is notnecessarily simple and results may not be a simple arithmetic sum. Thepresent invention provides a PEG-albumin preparation with a high osmoticactivity that retains overall native structure.2. Analysis of the ligand binding properties of PEG-albumin—Albuminbinds a number of important ligands, including sodium ions, bilirubin,magnesium ions, fatty acids and many drugs. Ligands bind at multiple,distinct sites on the three major domains of albumin (131a, 132a). Weexamined whether modification of albumin with PEG alter binding ofimportant ligands. Representative ligands that bind to the various sitesincluding bilirubin (137a), fatty acids (138a), heme (139a) and variousdrugs (125a) are examined. While binding of these ligands can bemeasured by spectroscopic assays (131a), the most informative andthermodynamically rigorous approach is titration calorimetry (ITC)(140a-142a). A solution of ligand is titrated into a protein solutionand the heat released or absorbed during binding is measured. Thisapproach requires no chromophor and is applicable to any ligand andacceptor. ITC experiments give the association constant, bindingenthalpy, binding entropy and the stoichiometry. The only significantlimitations relate to analysis of tight binding and weak ligands andligands of limited solubility. The extent to which modification altersligand binding is determined by examining binding isotherms for theligand to determine the binding constant(s) and the number of bindingsites. The present invention also provide examples of ligands that areuseful to evaluate the functional integrity of the three binding sitesin the modified albumins compared to unmodified albumin.

EXAMPLE IV-5c Determination of the In Vivo Half-Life and ToxicologicalEvaluation of PEG-Albumin

1. Determination of the Half-Life of PEG-Albumin—The half-life ofPEG-albumin is a consideration both in its efficacy and possible sideeffects. PEG modification of proteins in general (116a, 119a) andalbumin specifically increases the half-life, reduces antigenicity, andreduces their susceptibility to proteolysis. PEG modification has aprofound effect on the half-life of interferon α (from 6 hrs to 75 h)and its therapeutic effectiveness in treating hepatitis c (143a, 144a);with bovine albumin the change in half-life in rabbits is modest (143a).The latter result with albumin is not unexpected as it is a relativelylong-lived protein (20 days in humans) even without PEG modification. Assuch, PEG albumin and normal albumin modified with fluorescein or TexasRed is administered; these fluorophors provide a signal for monitoringclearance from the circulation. Use of the two chromophors, one onunmodified albumin and the other on the PEG modified albumin allows forthe two types of albumin to be monitored in the same animal so that theextent of preferentially retention in the circulation can be assessed.We have prepared both of these dye-albumin conjugates. The dye-albuminconjugates are administered to animals essentially as tracers and smallblood samples (˜100 to 200 μl) are taken through the tail vein over oneto two weeks for analysis. Clearance if followed by qualitatively byexamining the protein by Western blot analysis using a commerciallyavailable monoclonal antibody specific for human albumin; this approachavoids any effects that addition of a fluorophor to the protein mighthave. PEG-albs have dramatically different migrations on SDS gelscompared to unmodified albumin and the monoclonal antibody discriminatesbetween human and rat albumin. Using antibody specific for the humanalbumin, clearance is monitored quantitatively using an enzyme-linkedimmunoassay (ELISA); use of an antibody requires verification that thatit still binds to albumin after PEG modification.2. Analysis of the Toxicological Properties of PEG-Albumin—For PEGmodified albumin to be effective in treating capillary leak syndrome itmust be administered at relatively high doses compared to other PEGmodified proteins that have been used therapeutically, such asinterferon. An obvious difference is that a gram or more of PEG modifiedalbumin must be given compared to micrograms of interferon. It isessential that PEG albumin not be significantly toxic at these doses.Relatively large doses of higher molecular weight PEGs (4000 to 6000M_(r)) show little toxicity in a number of animals (rats, rabbits anddogs)(45a, 143a, 145a-147a) while some evidence suggests that the lowermolecular weight PEGs (e.g., 400 M_(r)) exhibit toxicity (45a, 148a,149a). A large fraction of blood volume of dogs (30 to 50%) can bereplaced with PEGylated hemoglobin without significant toxicity over twoweeks (149a). In some studies where large amounts were administered,inclusions in cells of the liver and kidney were observed, indicative ofphagacytosis. In most studies of toxicity, free PEG was examined and notPEG coupled to a relatively long-lived protein. Daily intravenous dosesof PEG 4000 administered to dogs at up to 90 mg/Kg for one year elicitedno toxic effects (150a); there were no gross anatomical, microscopic orbiochemical abnormalities. In experiments that would probably not beapproved by an IRB committee if they were proposed today, PEG 6000 wasadministered intravenously to six human volunteers with no apparent illeffect (146a); 94 to 99% of the PEG 6000 was excreted in the urinewithin 12 hours. PEGs in the 1000 to 10,000 M_(r) range are toxic inrats (147a) (LD₅₀ 10 to 20 gm/Kg), but only at doses that areapproximately 50 to 100-fold higher than those given in the studiesinvolving humans and dogs; the equivalent dose for a 75 Kg humanextrapolated from these studies would be 0.75 to 1.5 Kg. We have seen noovert toxicity in the studies we have performed, but since all of ourwork has examined short term effects that are evident in less than 4hours, toxicity arising from catabolism of PEG-albumin and release ofPEG-peptides would not be observed.Toxicological Evaluation

The most promising PEG-albumin conjugates are evaluated for toxicity byadministering them at doses in a range that starts with an anticipatedtherapeutic dose and going to much higher doses; animals are monitoredover periods of up to four weeks. Both single doses and multiple dosesare tested. Data collected prior to sacrifice of the animals includesbody weight, food consumption, water consumption, production of fecesand urine production. Also, the animals are observed for signs ofbehavioral changes. Small amounts of blood are withdrawn periodicallyand enzyme assays are performed on serum for markers characteristic ofhepatotoxicity. At the end of the experiment, the animals are sacrificedand tissues and organs are examined for macroscopic evidence of damage.A number of tissues are examined microscopically for evidence oftoxicity, including liver, kidney, lung, brain, heart and skeletalmuscle. Control animals that are given the vehicle are also examined inthe same fashion.

In the following Example V, the indicator reagent may be a dye or acombination of dyes. The two dyes may be red, green or the same color.Their emission and exitation wavelength has to be widely andsignificantly distant. The preferred method is on a double chromophoretechnique. However, it can be multiple chromophores.

A preferred dye is a red maleimide dye, Texas Red. Indocyanine Green isan excellent fluorescent material. It can be used to replace Texas Redin the mixture of Texas Red and Fluorescine. Indocyanine green emissionis in the near infrared (˜840 nm) and is an excellent tracer withdistant emission from fluoroscein.

The preferred use of this technique is the assay to be used as a markerto measure and quantify the vascular leak which is a surrogate formultiple organ failure. The implications is that of predicting patientsin danger of developing the organ failure. This allows the assay to beused to tailor certain therapies for such patients. Also this is a noveltechnique to study the half life of proteins.

In one embodiment, this invention is a technique of predicting thedevelopment of multiorgan dysfunction before it happens or earlier. Theprocess is based on administering two or more proteins. For example,albumin and PEG-albumin. The proteins have significantly differentmolecular weights and are tagged with chromophores with distant emissionand excitation wavelengths. Predicting occurs by assessing theconcentrations of the chromophores over time. Besides the albumins, wecan use for example another protein with known molecular weight. Forexample, immunoglobulin G molecular weight 150.000 or other proteinssuch as VonWillebrand factor MW 300.000.

EXAMPLE V Preparation of Dye Conjugated Albumin and PEG-Albumin

The methods for the preparation of dye conjugated albumin an PEG-Albwere as follows. Human albumin (50 mg/ml) was incubated 1 hr in 50 mMpotassium phosphate (pH 7.5), 150 mM NaCl, and 0.5 mM dithiothreitol.The dithiothreitol-treated albumin was incubated two hours with 4 mM5-iodoacetamidofluorescein or 1.5 mM Texas Red maleimide (MolecularProbes). The dye-modified albumins were diluted five-fold andreconcentrated three times in a centrifugal concentrator (10,000 Mr cutoff, Millipore) to remove most of the unincorporated dye, followed bydialysis for 48 hours against four changes of phosphate-buffered saline.

The fluorescein-labeled albumin was modified with methoxypolyethyleneglycol cyanuric chloride and purified by gel filtration on SephacrylS200. Fractions from Sephacryl S200 eluting with apparent molecularweights in excess of 200,00 were pooled and concentrated byultrafiltration employing a PM 10 membrane (Millipore) followed bydialysis against several changes of 0.9% saline. Analysis of thefluorescein- and Texas Red-labeled albumins by gel electrophoresisrevealed fluorescence was associated with the protein. No fluorescencewas detected at the positions of free dye. Steady state fluorescencemeansurements were made on a QM4SE fluorometer (Photon TechnologyInternational, Monmouth Junction, N.J.).

Next unmodified albumin and mPEG-Albs with fluorescein or Texas Redlinked through cys34 was prepared. These fluorescent albumin derivativeswere used to examine how effectively the albumin is retained in thecirculation in animals with capillary leaks. Disposition of thesealbumins can be monitored fluorometrically in body fluids or byfluorescence microscopy of tissue sections. The two fluorometrically inbody fluids or by fluorescence microscopy of tissue sections. The twofluorophores have well separated excitation and emission spectra, sosamples containing a mixture of two albumins (e.g., unmodified albuminwith Texas Red and PEG-albumin with fluorescein) can be examined in thesame animal. When PEG is linked through cys34, an amine reactiveversions of fluoroescein or Texas Red was coupled through a lysylε-amino group. Having albumin with two different fluorophores allows forthe determination of how efficiently the PEG albumin with fluorescein isretained in the circulation compared to the unmodified albumin with twodifferent fluorophores allows for the determination of how efficientlythe PEG albumin with fluorescein is retained in the circulation comparedto the unmodified albumin with Texas Red. These fluorescent albuminsonly were employed analytically for monitoring retention of unmodifiedversus PEG-albumin in models of shock or to monitor the in vivohalf-life. The fluorescence of fluorescein-albumin in dilutions of serumwas detected well above the background of other fluorescent material. Asnecessary, measurements of intensity were corrected for the inner filtereffect arising from other chromophores in serum samples. However,studies with the fluorescent albumin indicate that any interference isnegligible due to the large dilution of the serum that is required(1:1000 to 1:2000).

Animals/Measurement Protocol

Measurements were done in normal healthy rats (n=4) and CLP rats (n=11).For CLP, 6 rats were injected with (PEG-ALB-FL+Albumin-TR) and 5 wereinjected with the chromophores reversed. The Institutional Animal Careand Use Committee and the Academic Chemical Hazards Committee at theMedical College of Ohio approved experimental protocols. Animals werehoused in an American Association for Accreditation of Laboratory AnimalCare; International (AAALACI) approved facility. Adult maleSprague-Dawley rats (Charles River Laboratories, Portage, Mich.)weighing 400-480 grams were used. They were provided standard rat chowand water ad libitum. Prior to experiments, animals were fastedovernight, but given water ad libitum. We injected the fluorophores ofPEG-Alb and that of albumin using a cecal ligation and puncture (CLP)induced sepsis rat model and a sham model. Rats were anesthetized withsodium pentobarbital (50 mg/kg BW, i.p.) followed by pentobarbital asneeded. A laparotomy was perfoemd through a midline abdominal incision.The cecum was ligated just below the ileocecal valve with 3-0 silkligatures such that intestinal continuity was maintained. The cecum wasperforated with a 16-gauge needle in two locations and gently compresseduntil feces were extruded. The bowel was returned to the abdomen, andthe incision was closed with a layer of proline sutures for the musclesand 3-0 silk for the skin. Sham rats underwent the same protocol; thececum was manipulated but not punctured before the bowel was returned tothe abdomen. Three ml of sterile 0.9 percent sodium chloride solutionper 100 grams of body weight were administered subcutaneously on theback for resuscitation. The rats were deprived of food, but had freeaccess to water after surgery.

Twenty hours after surgery, animals were anesthetized and instrumentedto cannulate the internal jugular vein. Blood samples, each 100-150 μl,were taken at 40 minutes after injection (allowing for mixing of thechromophores and distribution in compartments), that is the time 0, thenat 30 minutes, 1 h, 3 h, 5 h, 8 h. After 8 h, the rats will be allowedto recover for 2 hours after discontinuation of the internal jugularline. More blood samples now will be taken from the tail vein at 22, 28,45, 52, 70, 96, 102, 148, 160, 171 hour or until the rat dies.

Histology/Fluorescence Microscopy

Formalin fixed lung and kidney tissues were subjected to standardprocessing, including a hematoxylin and eosin stain. For theimmunofluorescence studies, lung sections were examined with a NikonEclipse E800 fluorescence microscope and pictures recorded using ImagePro Plus Version 4.0 (Media Cybernetics, L.P.) using 20× and40×objectives.

Statistic Methods

Values are presented as mean±SD unless otherwise indicated. Within atreatment group, data analyzed at repeated time points (concentration offluorescence, time in hours) were evaluated by repeated measuresanalysis of variance using a post-hoc paired t-test employing correctionfor multiple comparisons. Differences among the treatment groups atcomparable time periods were evaluated with analyses of variance.Statistical significance is repreted at the p<0.05 and p<0.01 levels.

Results

The dye-albumin conjugates was administered to animals essentially astracers and small blood samples (˜100 to 200 microliters.) were takenthrough the Jugular vein (the first 8 hours) and through the tail veinthereafter. The disposition of these albumins was monitored by measuringthe fluorescence in the blood and by fluorescence microscopy throughexamining lung tissue sections. Using a method we developed,fluorescently labeled albumin and (Texas Red, TR) and PEG-Alb(fluorescein, F) were injected into rats and a small volume of blood istaken through the tail vein for analysis at times after injection. Ifalbumin is lost to the extravascular space and PEG-Alb is retained, theratio of fluorescein to Texas Red (F/TR) will increase with time,consistent with loss of albumin and preferential retention of PEG-Alb.The excitation and emission spectra of Texas Red and fluorescein aresufficiently different that mixtures of the two dyes can be examinedquantitatively in serum samples. Switching the labels (fluoresceinalbumin and Texas Red PEG-Alb) give exactly complementary resultsverifying that clearance of the protein is not a property of thefluorophores. The clearance exhibits a fast phase, consistent withredistribution of the material into another compartment and a slow phasereflecting clearance. The PEG-albumin is cleared ˜3 times less rapidlycompared to albumin. The distribution of albumin and PEG-Alb was alsoexamined qualitatively in frozen tissue sections of lung by fluorescencemicroscopy to determine if the PEG-Alb is retained within blood vessels,as we observed in septic shock.

To demonstrate that PEG-Alb is retained within vessels while normalalbumin leaks, a mixture of fluorescein-labeled PEG-Alb and Texas Redlabeled albumin was administered. Fluorescence microscopy of lungsections demonstrated co-localization of the Texas Red and fluoresceinsignals in rats subjected to sham surgery whereas in the CLP rats, TexasRed fluorescence (PEG-Alb) was detected only within vascular structures;colocalization of the dyes would indicate that both were retained whilethe presence of one of the dyes in the interstitial space would indicateleak of the labeled species.

FIGS. 31A and 31B show Albumin and PEG-Alb fluorescence data (log-scale)indeed to the concentration at injection time (Time=0). The graph isshown as a function of time averaged for all 11 CLP rats (FIG. 31A) andfor 4 normal rats (FIG. 31B). Lines represent the bi-exponential modelfits to the concentration data.

FIGS. 32A and 32B also show Albumin and PEG-Alb fluorescence data(log-scale) indexed to the concentration at injection time (Time=0). Thegraph is shown as a function of time for individual CLP rats. FIG. 32Ais a graph for 6 rats with PEG-Alb FL and Albumin-TR. FIG. 32B is agraph for 5 rats with PEG-Alb-TR and Albumin-FL. Corresponding analysisdata are shown in Table 1.

TABLE 1 Estimated bi-exponential time constants (τ₁, τ₂), τ₅₀ and AUCfrom the PEG-Alb and Albumin Fluorescence data over time in individualcecal ligation and puncture (CLP) rats. Time τ₁ τ₂ Rat# FL/TR (hrs) R²(hrs) (hrs) τ₅₀ AUC PEG-Alb 1 FL 144 0.99 0.47 34.1 14.6 30.2 2 FL 471.00 — 20.4 16.2 — 3 FL 48 0.99 — 29.2 15.6 — 4 FL 47 1.00 — 12.8 12.2 —5 FL 152 1.00 5.72 100.5 17.2 42.9 6 FL 124 0.99 5.09 59.5 8.6 27.1 7 TR171 0.99 1.38 44.0 25.1 39.5 8 TR 134 0.99 0.87 30.5 12.5 30.2 9 TR 341.00 — 9.1 4.8 — 10 TR 170 0.99 3.06 85.3 7.3 33.5 11 TR 124 0.99 4.9749.8 10.1 27.4 mean 109 0.99 3.1 42.4 13.1 33.7 SD 54 0.00 2.2 30.0 5.69.4 Albumin 1 TR 144 1.00 1.18 17.0 4.6 13.4 2 TR 47 1.00 — 11.9 8.3 — 3TR 48 1.00 — 14.0 7.2 — 4 TR 47 1.00 — 12.8 5.3 — 5 TR 152 1.00 3.0221.2 5.8 15.7 6 TR 124 1.00 2.03 15.4 3.9 11.2 7 FL 171 1.00 1.57 25.69.0 20.0 8 FL 134 1.00 0.64 18.0 4.5 14.8 9 FL 34 0.99 — 3.4 2.5 — 10 FL170 0.99 1.93 34.7 3.8 18.3 11 FL 124 1.00 3.31 27.0 5.1 13.9 mean 1091.00 1.95 17.6 5.4 15.3 SD 54 0.00 0.95 9.3 2.0 3.0 4-parameterbi-exponential model (y₀, a, τ₁, τ₂): [Concentration] = y₀ + a ·e^(−t/τ) ¹ + b · e^(−t/τ) ² ; [Concentration] refers to the [FL] or [TR]fluorescence indexed to baseline or time (t) = 0; b = 1 − (y₀ + a) sothat [FL]/[TR] = 1 at t = 0.

TABLE 2 Ratios (PEG-Alb/Albumin) of bi-exponential time constants (τ₁,τ₂), τ₅₀ and AUC for individual cecal ligation and puncture (CLP) rats.Rat # τ₁ Ratio τ₂ Ratio τ₅₀ Ratio AUC Ratio 1 0.40 2.01 3.22 2.25 2 —1.69 1.96 — 3 — 2.09 2.18 — 4 — 1.54 2.28 — 5 1.90 4.74 2.95 2.74 6 2.503.85 2.18 2.41 7 0.88 1.72 2.78 1.98 8 1.38 1.70 2.77 2.04 9 — 1.44 1.9310 1.59 2.46 1.95 1.84 11 1.50 1.85 2.00 1.98 mean 1.86 2.28 2.38 2.18Std. Dev. 1.62 1.20 0.46 0.31 AUC = area under the curve calculatedbetween 0 and 120 hours only for rats surviving >5 days; τ₂ Ratio = 2.62± 1.20 for CLP rats surviving >5 days (n = 7).

Both fluorescein labeled PEG-Alb and Texas Red labeled albumin were seenonly in the intravascular space of control animals. These results areconsistent with the retention of PEG-Alb in blood vessels duringcapillary leak.

FIG. 33 shows PEG-Alb/albumin fluorescence data indexed to theconcentration at injection time (Time=0) as a function of time forindividual normal & CLP rats. Increased vascular permeability is anearly feature of SIRS. It precedes by days the overt development ofmultiorgan dysfunction syndrome (MODS). During systemic inflammatoryresponse conditions (SIRS) such as sepsis, trauma, albumin leakage rateincreases substantially. Accurate identification of patients destined todevelop MODS will enable therapeutic strategies very early to be appliedto limit the disease process. When albumin is lost to the extravascularspace (Texas Red) and/or PEG-Alb (labeled with Ftc) is retained, thenthe ratio of Ftc/TR is expected to increase with time. Progressiveincrease of PEG-Alb/albumin ratio as a surrogate for increased capillarypermeability in Systemic Inflammatory Response (SIRS) conditions isshown above in FIG. 33. We describe a double chromophore technique forearly detection of CL based on tagging albumin and a larger polyethyleneglycol modified albumin (PEG-Alb) with spectroscopically distinctchromophores [fluorescein (FTC) and Texas Red (TR), respectively].Eleven sepsis (cecal ligation and puncture; CLP) and 4 normal rats wereinjected with tracer amounts of both tagged proteins and theirconcentrations were repeatedly assessed by fluorescent spectroscopy upto 144 hours post injection. Intravascular PEG-Alb decreased at a lowerrate compared to albumin for both normal and CLP rats (ratio>1(increasing); FIG. 33. The increase in PEG-Alb to Albumin ratio wassimilar for CLP and normal rats during days 1 and 2 post-injection.After day 2, when CL is likely to have occurred in septic rats, thisratio continued to increase in CLP rats while it remained unchanged innormal rats. The observed time point at which the sepsis-to-normalchromophore ratios separate might indicate onset of significant CLwhereas the difference between the two curves is possibly a reflectionof severity (Fig). These findings represent the basis of a noveltechnique for detection of CL.

vFluorescence concentration of PEG-Alb/albumin in both normal and CLPrats was not significantly different at the first part of the curve, upuntil 40 hours after tracer injection or 60 hours after CLP. The upwardslope of the curve suggests more retention of PEG-Alb or loss ofalbumin. In normal rats significant albumin loss it is not expected,decreased clearance of PEG-Alb is responsible for the increase in theratio in normal and CLP rats at this relatively early phase of CLP. Inthe CLP rats, severe capillary leak was expected to occur after 48 hoursafter the onset of CLP. At this stage, PEG-Alb/albumin ratio in the CLPrats progressively increased after 60 hours, suggesting albumin lossconsistent (with capillary leak) in addition to decreased clearance ofPEG-Alb. The area under the CLP curve and above the normal rats curvemeasures the capillary leak or the organ dysfunction index.Quantification of capillary leak is important to predict pateitnsdestined to develop MODS. In relation to this, the use of this index canguide the use of expensive treatments for sepsis (example activatedprotein C or Xigris™) early before the overt development of MODS. Whatguides activated protein C use in severe sepsis is the measured APACHEII score where if >25 have shown to decrease absolute mortality by 6%.Although APACHE II scores are an indication of the severity of illnessin populations of patients, they may be less useful in predicting theoutcome of individual patients.

This invention uses multiple proteins or molecules with differentmolecular weights and tagged with different fluorophores each withdistinct and distant emission and excitation wavelengths. These areadministered to a patient at risk of developing multiorgan dysfunction.The, the process follows their concentrations (under the samepathophysiological processes such as hemoconcentration and capillaryleak) serially at multiple times.

While this invention has been described with emphasis upon preferredembodiments, it would be obvious to those of ordinary skill in the artthat preferred embodiments may be varied. It is intended that theinvention may be practiced otherwise than as specifically describedherein. Accordingly, this invention includes all modifications andclaims spirit and scope of the appended claims.

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1. A composition comprising a polyethylene glycol-albumin colloid composition having Cys-34 preserved as a thiol (PEG-Alb_(Cys-34)), wherein PEG-Alb_(Cys-34) has a hydrodynamic radius that is sufficiently large to preclude the composition from leaking through a patient's capillaries and is 13 fold larger than the hydrodynamic radius of an albumin protein, wherein the PEG-Alb_(Cys-34) is human albumin or bovine serum albumin modified with an indicator reagent; wherein the indicator reagent is a first dye having an emission and excitation spectra and a second dye having an emission and excitation spectra, wherein the emission and excitation spectra of the second dye is distinct from that of the first dye.
 2. A composition according to claim 1 wherein the first dye has a green color and the second dye has a red color.
 3. A composition according to claim 1 wherein the first or second_dye has a green color.
 4. A composition according to claim 1 wherein the first or second_dye is a red maleimide dye or indocyanine green.
 5. A composition comprising a polyethylene glycol-albumin colloid composition having Cys-34 preserved as a thiol (PEG-Alb_(Cys-34)), wherein PEG-Alb_(Cys-34) has a hydrodynamic radius that is sufficiently large to preclude the composition from leaking through a patient's capillaries and is 13 fold larger than the hydrodynamic radius of an albumin protein, wherein the PEG-Alb_(Cys-34) is human albumin or bovine serum albumin modified with 5-iodoacetamidofluorescein.
 6. A composition according to claim 5 wherein the PEG-Alb_(Cys-34) further comprises indocyanine green.
 7. The composition of claim 1 wherein the polyethylene glycol-albumin colloid composition is a dithiothreitol-treated albumin composition.
 8. A composition comprising a polyethylene glycol-albumin colloid composition having Cys-34 preserved as a thiol (PEG-Alb_(Cys-34)), wherein PEG-Alb_(Cys-34) is human albumin or bovine serum albumin modified with an indicator reagent, wherein the PEG-Alb_(Cys-34) has a molecular excluded volume and a hydrodynamic radius sufficiently large to preclude the composition from leaking through a patient's capillaries and the molecular excluded volume of PEG-Alb_(Cys-34) is 16 fold larger than the molecular excluded volume of an albumin protein.
 9. A composition comprising a polyethylene glycol-albumin colloid composition having Cys-34 preserved as a thiol (PEG-Alb_(Cys-34)), wherein PEG-Alb_(Cys-34) is human albumin or bovine serum albumin modified with an indicator reagent, wherein the PEG-Alb_(Cys-34) has a molecular excluded volume and a hydrodynamic radius sufficiently large to preclude the composition from leaking through a patient's capillaries and the hydrodynamic radius of the PEG-Alb_(Cys-34) is 13 fold larger than the hydrodynamic radius of an albumin protein. 